Docstoc

INTESTINAL OBSTRUCTION - PDF

Document Sample
INTESTINAL OBSTRUCTION - PDF Powered By Docstoc
					                                                                                             Intestinal obstruction 1



Chapter 1

                INTESTINAL OBSTRUCTION
Definition                                                       Extra mural

Lack of transit of intestinal contents is called intestinal   Intraluminal Causes
obstruction.                                                     Impacted faeces, e.g., bed ridden patients, old people
                                                                 Foreign bodies
CLASSIFICATION                                                   Bezoars
Classification of intestinal obstruction can be made             Gallstones
according to –                                                   Ascariasis
 Pathology                                                     Food bolus (in poorly masticating individuals with
 Anatomy                                                         gastric bypass)
 Nature of presentation and                                    Meconium ileus
 Pathological changes in the bowels                         Intramural causes
1) Classification according to pathology                         Atresia
                                                                 Inflammatory strictures –
   Dynamic: where peristalsis is working against a                Tuberculosis
     mechanical obstruction                                         Crohn’s disease
   Adynamic: where there is absence of peristalsis             Malignant stricture
     without obstruction
      Absent peristalsis (e.g. Paralytic ileus)
                                                              Extramural causes
      Non- propulsive form (e.g. Mesenteric vascular           Intraperitoneal bands and adhesions
         occlusion and pseudo-obstruction)                       Hernia
                                                                 Volvulus
2) Classification according to anatomy                           Intussusception
   Small bowel obstruction –                                PATHOPHYSIOLOGY OF INTESTINAL
      High or
                                                              OBSTRUCTION
      Low
   Large bowel obstruction                                     The intestinal obstruction causes local changes in the
                                                                   bowel and systemic changes.
3) Classification according to the nature
of presentation                                               Changes in the bowel
   Acute                                                       Distal collapse
   Chronic                                                     Proximal dilatation
   Acute on chronic                                            Strangulation of the bowel wall
   Subacute                                                    Changes due to closed loop obstruction

4) Classification according to                                Proximal dilatation
pathological changes                                             Following obstruction to the bowel, initially, hyper-
                                                                   peristalsis occurs proximally to overcome the
   Simple: where the blood supply is intact                      obstruction. Later in persistent obstruction, dilatation
   Strangulated: where there is direct interference to           occurs with absent peristalsis
     blood flow
                                                              Causes of dilatation
DYNAMIC INTESTINAL OBSTRUCTION                                   1) Gas accumulation
                                                                 2) Fluid accumulation
Causes
                                                              1) Gas accumulation
   Intra luminal                                            Causes of gas accumulation
   Intra mural

                                                                                       Yogi Ram’s lectures on Surgery
 60% from swallowed air                                                       Peritonitis and septicaemia
 30 % due to diffusion from blood through the
   devitalised bowel wall and                                         2) When long segments of bowel are strangulated,
 10% of air from decomposition of food products by              sequestration of blood occurs in the strangulated segment
   bacteria                                                                                     
Composition of gases                                                                 Hypovolaemic shock
                                                                 These two complications – peritonitis and hypovolaemia
   O2 and CO2 from swallowed air is absorbed into the          are infrequent in strangulated external hernia because of
     blood                                                       smaller absorptive area of sac, which is separate from the
   The remaining gas contains mainly H2S, N2, partly           rest of the peritoneal cavity and shorter segments of
     methane, and H2.                                            involved bowel.
2) Fluid accumulation                                            Closed-loop obstruction
Causes of fluid accumulation                                     This occurs when the bowel is obstructed at both the
             Impaired absorption from the gut                    proximal and distal point. There is no early distension of
                                                                the proximal intestine, but the closed loop distends
        Sequestration of fluid in the bowel lumen                enormously.
    This fluid is derived from various digestive juices          Examples
Approximate volumes of digestive juices                             Volvulus
produced by the gut in 24 hours
                                                                    Herniation of bowel
                                                                    Tight carcinomatous stricture of colon with a
      Saliva                   1000 – 1500 ml                         competent ileocaecal valve: it causes increased intra-
      Gastric juice            1500 – 2500 ml                         luminal pressure, greatest at the caecum 
      Bile                     1000 ml                                impairment of blood supply of caecum  necrosis and
      Pancreatic juice         1500 ml                                perforation of caecum
      Succus entericus         3000 ml
                                                                 SYSTEMIC CHANGES FOLLOWING
Strangulation                                                    INTESTINAL OBSTRUCTION
Causes
                                                                    Reduced oral intake, defective intestinal absorption
Compromised blood supply occur to the intestines in
                                                                      and vomiting  dehydration  shock and its sequelae
intestinal obstruction due to:
                                                                    Strangulation  hypovolaemic shock
 Rising intraluminal pressure in the proximal bowel
                                                                    Distension  respiratory embarrassment
 Closed-loop obstruction
                                                                    Transmigration of bacteria and toxins  septicaemia
 External compression of the bowel
                                                                      and toxaemia
      Hernial orifices
      Adhesions/bands                                               Shock, respiratory embarrassment, septicaemia,
      Volvulus,                                                                        toxaemia
      Intussusception                                                                      
 Interruption of mesenteric flow due to vascular                                        MODS
     pathology
Pathology of strangulation                                       CLINICAL FEATURES
   1) Initially, the venous return is compromised due to         Classical quartet of
                         dilated bowel                            Pain
                                                                 Distension
                 Increase in capillary pressure                   Vomiting
                                                                 Absolute constipation and
Local mural distension due to fluid and cellular exudation        In dynamic obstruction, increased bowel sounds
                                                                    (borborygmi)
                 Compromised arterial supply
                                                                Pain
                  Haemorrhagic infarction
                                                                    Sudden, severe and colicky pain around the umbilicus
                                                                     (small bowel) or lower abdomen (large bowel)
Translocation of intestinal bacteria and their toxins into the
                                                                    The pain coincides with increased peristaltic activity
                       peritoneal cavity
                                                                    Later, pain becomes constant and diffuse due to
                               
Yogi Ram’s lectures on Surgery
                                                                                               Intestinal obstruction 3

     distension                                                 CLINICAL PRESENTATION
   In strangulation, pain is severe and constant
                                                                These features vary according to
Vomiting
                                                                   The onset of obstruction
   As the obstruction progresses, the character of
                                                                   Acute, subacute or acute on chronic
     vomitus alters from undigested food to faeculent
                                                                   The site of the obstruction
     material.
                                                                      Jejunal, ileal or colonic
   Distal the obstruction, longer the interval for the
     appearance of nausea and vomiting.                            The duration of the obstruction
                                                                   The cause of the obstruction
Distension                                                         The presence or absence of strangulation
   In the small bowel, the distension is central and is       Clinical presentation depending upon onset
     greater in the distal lesions                              Acute obstruction
   In colonic obstruction, it is delayed and peripheral
                                                                   Sudden onset of severe colicky, central abdominal
   Visible peristalsis (step-ladder pattern) is usually            pain
     associated.
                                                                   Distension
   It may be minimal or absent in mesenteric vascular
                                                                   Early vomiting and
     occlusion
                                                                   Constipation
Constipation                                                    Chronic obstruction
  This may be absolute (i.e. passage of neither faeces           Pain
    nor flatus) or relative (where flatus only is passed).         Constipation
 Absolute constipation is a cardinal feature of complete      Acute on chronic obstruction
    intestinal obstruction.
The constipation is not present in intestinal obstruction due      History of distention and vomiting in a patient with
to                                                                   past H/O pain and constipation
 Richter's hernia                                             Subacute obstruction
 Gallstone obturation                                            Recurrent attacks of colic relieved by passing flatus or
 Mesenteric vascular occlusion                                     faeces
 Obstruction associated with a pelvic abscess
 Partial obstruction (faecal impaction/colon neoplasm)
                                                                Clinical presentation depending upon the site
    where diarrhoea may often occur.                            of obstruction
Late manifestations                                             High small bowel obstruction
                                                                   Vomiting occurs early and is profuse with rapid
   Dehydration  Hypovolaemic shock Oliguria                      dehydration
   Pyrexia, septicaemia                                          Distension is minimal with little evidence of fluid
   Respiratory embarrassment and peritonism                        levels on abdominal radiography
   MODS
                                                                Low small bowel obstruction
Shock                                                              Pain is predominant with central distension
Causes                                                             Vomiting is delayed
   Fluid and electrolyte imbalance                            Large bowel obstruction
   Sequestration of blood in the gangrenous bowel                Constipation is early and pronounced
   Septicaemia                                                   Pain is mild and
Pyrexia                                                            Vomiting and dehydration are late
                                                                   The proximal colon and caecum are distended on plain
Pyrexia in the presence of obstruction indicates
                                                                     X ray abdomen
 The onset of ischaemia
 Intestinal perforation                                       Clinical features of strangulation
 Inflammation associated with the obstruction                 The diagnosis is entirely clinical –
(Hypothermia indicates septicaemic shock)                        Features of shock
                                                                 Local tenderness with rigidity/rebound tenderness
Abdominal tenderness
                                                                 Later, generalized tenderness and rigidity
   Localized tenderness indicates ischaemia.                   In strangulated external hernia, the lump is tense,

                                                                                         Yogi Ram’s lectures on Surgery
     tender, irreducible, without the expansile cough             In adults, two inconstant fluid levels at the duodenal
     impulse with recent increase in size.                          cap and in the terminal ileum

INVESTIGATIONS                                                 Contrast X ray
Aims of the investigations                                        A barium follow-through is contraindicated in the
                                                                    presence of acute obstruction and may be life-
   To diagnose the obstruction                                    threatening.
   To diagnose the site of obstruction                          Barium enema can be given, but water soluble contrast
   To diagnose whether strangulation has supervened               X rays are preferable
Plain X- ray abdomen                                           Haematological investigations
  Most useful investigation to diagnose the obstruction,        Total leucocyte count: more than 15,000 /mm3 suggest
    its site and duration (early or late)                           strangulated obstruction
Supine and erect films are taken. In a case of intestinal      (The other cardinal features of strangulated obstruction
obstruction, it shows –                                        are– disproportionate shock, rebound tenderness, bleeding
 Gas shadows and air-fluid levels                            per rectum)
 Radio opaque foreign bodies (e.g., gall stones,
    metallic foreign body) causing the obstruction             TREATMENT OF ACUTE INTESTINAL
Gas shadows                                                    OBSTRUCTION
   They are due to proximal distended bowel containing       Principles of treatment
     gas
   Better seen on a supine film                                Resuscitation
   The mucosal pattern of the distended gut can be                Fluid and electrolytic replacement (drip)
     identified making the diagnosis of the site of                 Gastrointestinal drainage (suction)
     obstruction and the diameter of the distended viscus or    Relief of obstruction
     the site of the gas shadow is not diagnostic                   Conservative treatment
                                                                    Surgical treatment
Jejunum                                                        The resuscitation (drip and suction) is necessary as a pre-
   Dilated loops are seen centrally and lie transversely.    operative preparation and for postoperative management.
   No gas is seen in the colon.
   Characterized by its valvulae conniventes that            Conservative treatment
     completely pass across the width of the bowel and are     Indications:
     regularly spaced giving a ‘concertina’ effect.
                                                                Adhesions, worms, faecal impaction
Ileum                                                          Procedure
   Featureless.
                                                                  Drip and suction
Colon                                                             Soap water enema
   A distended caecum is shown as a rounded gas                    It relieves obstruction in
     shadow in the right iliac fossa                                     Faecal impaction of old people
   Remaining colon shows haustral folds which are                      Ascarial obstruction
     spaced irregularly and the indentations are not placed              Intussusception
     opposite one another                                            It is contraindicated in
   Volvulus of sigmoid colon has distinct features with                Suspected gangrene of the bowel
     out haustrations (coffee-seed appearance of the                     Peritonitis
     distended bowel)
                                                               Surgical treatment
Air-Fluid levels
   Seen on erect film                                        Preoperative management
   Due to the sequestrated fluid in the proximal bowel          Drip and suction
   They are seen few hours after the onset of obstruction          Replacement of fluids by Ringer lactate or normal
   More fluid levels = advanced obstruction/distal                    saline, as the losses are mostly of Na, Cl and K
     obstruction/ atonic paralysis                                   Blood transfusion, if there is evidence of
Physiological fluid levels                                              strangulation
                                                                     Nasogastric decompression
   In infants less than 2 years of age in the small bowel
Yogi Ram’s lectures on Surgery
                                                                                                   Intestinal obstruction 5


   Monitoring                                                     2) Management of small bowel obstruction
      For shock                                                  The type of surgical procedure required would depend
      For progress of obstruction                                upon the nature of the cause after decompressing the
      For features of strangulation                              proximal distended bowel, which aids in surgical
   Antibiotics                                                   management and postoperative recovery.
Surgical treatment                                                 Decompression
                                                                   Indications
The timing of surgery                                               If dilatation of bowel loops prevents exposure
Indications for early operation                                     If the viability of the bowel wall is compromised
   Obstructed or strangulated external hernia                    It is done with Savage decompressor or Ryles’ tube passed
   Internal intestinal strangulation                             through an opening in the bowel guarded by a
   Closed loop obstruction                                       seromuscular stitch
                                                                   Surgical procedures for small bowel obstruction
Indications for delayed operation
                                                                   The procedures are dependent upon the disease and one of
   Adhesive obstruction where there is no pain or                following is done.
     tenderness                                                     Division of adhesions (adhesiolysis)
Operative procedure                                                 Excision of the diseased segment and anastomosis
It depends upon –                                                   Bypass
 The site and nature of obstruction                              3) Assessment and management of viability of
 The viability of the gut                                        gut
1) Detecting the site of obstruction                               Following relief of obstruction, the viability of the
After laparotomy, the caecum is identified. A dilated              involved bowel is assessed. If in doubt, the bowel should
caecum indicates large bowel obstruction and a collapsed           be wrapped in hot packs for 10 minutes with increased
caecum, small bowel obstruction. The site of obstruction in        oxygenation and reassessed.
small intestine is identified by careful retrograde                Differentiation between viable and nonviable
assessment.                                                        bowel
                     INTESTINE                        VIABLE                           NONVIABLE
                Circulation                  Dark color becomes lighter        Persistent dark colour
                                             Mesentery bleeds, if pricked      No bleeding, if mesentery is
                                                                               pricked
                Peritoneum                  Shiny                              Dull and lustreless
                Intestinal                   Firm,                             Flabby, thin and friable
                musculature                 Pressure rings may or may not       Pressure rings persist
                                            disappear                           No peristalsis
                                             Peristalsis is observed
                Mesenteric vessel           Normal pulsations                  Absent
                pulsations
Management of non-viable bowel                                          done after decompressing the colon with on-table
                                                                        lavage and protective proximal colostomy
   If the bowel is found non-viable, resection of non-              If the lesion is irremovable or the patient is not fit, by-
     viable segment and end to end anastomosis is done                  pass operation (Ileotransverse colostomy or
   If the bowel is of doubtful viability, e.g., mesenteric            transverse-pelvic colostomy) or colostomy,
     ischaemia and not resected, a relook operation is                  caecostomy or ileosotomy (if the ileocaecal valve is
     performed 48 hours later                                           incompetent) is done.
Management of large bowel obstruction                                 If the growth is operable, but the patient is not fit, one
                                                                        of the following is performed –
   If the caecum is distended, it is a large bowel
                                                                         Paul-Mickulicz’s operation with resection of
     obstruction. Sigmoid is identified and followed
                                                                             growth (to facilitate subsequent extraperitoneal
     proximally. When a resectable lesion is found in a fit
                                                                             closure)
     patient, right hemi colectomy is performed for right
     colon lesions.                                                      Hartmann’s operation
   For rest of the colon, for operable growths, resection is           Colostomy with mucus fistula


                                                                                             Yogi Ram’s lectures on Surgery
6 Intestinal obstruction – specific diseases and management



Chapter              2
             INTESTINAL OBSTRUCTION –
               SPECIFIC DISEASES AND
                   MANAGEMENT
ACUTE INTESTINAL OBSTRUCTION OF                               advised.
THE NEWBORN                                                   Volvulus neonatorum
Causes                                                        It is volvulus of the mid gut due to defective rotation of the
                                                              gut during development of the gut.
   Congenital atresia and stenosis (commonest causes)
   Volvulus neonatorum                                      Development of the gut
   Meconium ileus                                           There are four stages in the development of the gut –
   Hirschsprung's disease                                    A) Development of primitive gut into foregut, midgut
                                                                  and hindgut
Congenital atresia or stenosis                                 B) Physiological herniation of midgut
   Sites: duodenum (common), jejunum, ileum,                 C) Rotation of midgut for returning into abdomen
     ascending colon or multiple sites                         D) Fixation
   There may be associated cardio-vascular anomalies        Rotation of the midgut
Aetiology                                                     The midgut stays in the extra embryonic coelom (in the
   Intrauterine localised bowel ischemia, which later is    umbilical cord) during early embryonic life (5th week).
     absorbed and replaced by scar tissue.                    Persistence of this abnormality causes omphalocele
                                                              (exomphalos). Later, it retrieves into the abdomen. For
Atresia of the duodenum                                       proper retrieval, it rotates in three stages –
See chapter on diseases of stomach                             I stage: 5th – 10th week
Atresia/stenosis of the jejunum/ileum                          II stage: 10th – 11th week
                                                               III stage: 11th – before birth
Pathology
                                                              I stage of rotation
Proximal to the atresia, the bowel is grossly distended and
sometimes may lead to gangrene                                Development of liver causes displacement of umbilical
                                                              vein in the umbilicus. This displaces the prearterial loop
Clinical features                                             down and to right.
  Abdominal distension, which may be early or within        II stage of rotation
    24 hours of birth
                                                              The midgut loop returns to abdomen in a definite order.
 Bilious vomiting
                                                              Proximal portion of prearterial segment returns first. The
Investigations                                                gut returns to the right of the artery and enters the
 Plain X ray abdomen                                        abdominal cavity behind the vessel. The entering loops of
Surgery                                                       midgut pushes the hindgut mesentery and hindgut to left
                                                              by displacing the hind gut to the left. The last coil of ileum
As there is discrepancy in bowel diameter above and           is reduced with the artery. Later, the caecum and ascending
below the obstruction, anastomosis is difficult to perform.   colon reduces. This makes the caecum, ascending and
Ileal atresia                                                 transverse colon to lie anterior to the artery.
Paul-Mickulicz’s procedure and secondary closure is done      II stage - summary
4 – 7 days later.
                                                                 Duodenum crosses behind the superior mesenteric
Jejunal atresia                                                    artery
Because of high output discharge following Paul-                 Transverse colon lies in front of the vessel
Mickulicz’s procedure, resection and anastomosis is              Descending colon is pushed to left
Yogi Ram’s lectures on Surgery
                                                        Intestinal obstruction – specific diseases and management 7

 Duodenocolic isthmus becomes wide                                 Features of duodenal obstruction+ air fluid levels in
III stage of rotation                                                  small intestine
Caecum descends down. Ascending and descending colon              Treatment - surgery
fixed to posterior parities                                          Laparotomy
Errors in rotation                                                   Reduction of volvulus by untwisting and division of
                                                                       any secondary obstructive lesion - such as the
    Errors in I stage occurs very rarely –
                                                                       transduodenal band of Ladd
       It presents as extroversion of cloaca
 Errors in II stage                                             Meconium ileus
       Non rotation or arrested rotation
       Reversed rotation                                        = Intestinal obstruction due to meconium
       Mal rotation                                             Pathology
 Errors in III stage                                            Meconium is normally kept fluid by the action of
       Subhepatic caecum                                        pancreatic enzymes. In cystic fibrosis, due to absence of
       Mobile ascending colon                                   pancreatic secretion, the meconium in the terminal ileum
Arrested or non-rotation                                          becomes viscid resulting in inspissation in-utero causing
It is the most common anomaly. The second stage of                neonatal obstruction.
rotation is absent, loop reduces inside as such, and the          Clinical features
caecum occupies the left side of the abdomen, usually in             Family history may be present
the left hypochondrium to the left of artery.
                                                                     Features of acute intestinal obstruction in new born
This is associated with a band passing from the caecum to
abdominal wall across the second part of the duodenum -           Investigations
the transduodenal band of Ladd.                                      Plain X ray abdomen
 Clinical features and X ray are similar to duodenal               Distended small intestine with mottling. Fluid levels
      atresia.                                                         are generally not seen.
 Treatment: division of the band of Ladd                           Absence of trypsin from stool or vomitus
Reversed rotation                                                       Into bowl of vomitus, a piece of exposed
The caecum reduces first but to the right of artery                        radiograph film is placed for half an hour. If
transverse colon lies behind the artery. Duodenum lies in                   trypsin is present in the vomitus, the gelatine coat
front of the artery.                                                        of the film is digested. In the meconium ileus, due
                                                                            to absence of trypsin, the film becomes soft and
Effects of anomalies of rotation                                            will not loose its gelatine coat.
   No functional disturbance                                       Estimation of Na Cl in the sweat
   Non rotation results in narrow duodenocoloic isthmus               Concentration of sodium chloride in the sweat is
     with a free hanging loop of midgut loop                               greater than 80 mmol/litre (salty kiss)
     predisposes to volvulus of midgut                               Contrast X ray
   These anomalies may be associated with congenital                  Done with gastrografin, when there is partial
     bands (e.g., band of Ladd) which may cause intestinal                  obstruction
     obstruction                                                        It may disperse the obstructing meconium and
   Mobile caecum and ascending colon  volvulus of                        relieve the condition owing to its high osmolarity
     caecum and colon                                                       and detergent action
Volvulus neonatorum                                               Differential diagnosis
                                                                     Hirschsprung's disease affecting the whole colon.
Cause
                                                                  Treatment
   Arrested rotation
                                                                  If conservative management fails, laparotomy is indicated
Pathology                                                         and Bishop-Koop operation is performed.
   The volvulus is in a clockwise direction                     Bishop-Koop operation
Clinical features                                                 Resection of the most dilated segment of the intestine is
   Severe distention, vomiting and rapid dehydration in a       done with an end-to-side anastomosis of the proximal part
     newborn child or few weeks after birth                       of the ileum to the side of the lower segment of the ileum.
                                                                  The distal ileal opening is formed into an ileostomy,
Investigation                                                     through which the meconium may be irrigated
   Plain X ray abdomen                                          postoperatively. The ileostomy becomes a mucus fistula,

                                                                                           Yogi Ram’s lectures on Surgery
8 Intestinal obstruction – specific diseases and management


which is closed later.                                        Clinical features
Necrotising enterocolitis                                        Colic
                                                                    Sudden onset of screaming associated with
It is commonly seen in sick premature neonates.                         drawing up of the legs.
Pathology                                                           The attack last for a few minutes, recur every 15
                                                                        minutes and becomes progressively severe.
   Mucosal to transmural necrosis of intestines
                                                                 Later, vomiting and passage of red current jelly stool
Clinical features                                                Unrelieved, peritonitis occurs due to gangrene
   Features of enterocolitis with toxaemia and lethargy        On examination, a lump may be felt which hardens on
                                                                   palpation in 50 – 60 per cent of cases.
Plain X ray abdomen
                                                                 There may be feeling of emptiness in the right iliac
   Pneumatosis intestinalis or free intraperitoneal air.         fossa (the sign of Dance).
Treatment                                                        On per rectal examination, blood stained mucus and
                                                                   occasionally, in extensive ileocolic or colocolic
   Excision of all necrotic bowel with primary
                                                                   intussusception, the apex may be palpable or even
     anastomosis
                                                                   protrude from the anus.
INTESTINAL OBSTRUCTION IN INFANTS                             Investigations
AND CHILDREN                                                     Plain X ray abdomen
                                                                    Evidence of small or large bowel obstruction with
Acute intussusception                                                  an absent caecal gas shadow
This occurs when one portion of the gut becomes                  Barium enema
invaginated within an immediately adjacent segment;                 The claw sign in ileo-colic or colocolic form
usually, the proximal into distal bowel.                         CT scan
                                                                    Equivocal cases may be evaluated by CT scan to
Aetiology
                                                                       reveal the presence of a small bowel mass
   Idiopathic: 70 – 95%                                        Laparotomy
      Seen in infants of 3 – 9 months of age                      It should be considered in equivocal cases
      ? Due to hyperplasia of Payer's patches secondary
         to weaning or upper respiratory tract infection      Differential diagnosis
   Secondary                                                  Acute enterocolitis:
      Seen in adults                                             Abdominal pain and vomiting are common with
      Associated with a lead point, Meckel's                       occasional blood and mucus in the stool,
         diverticulum, polyp, submucosal lipoma or                 Diarrhoea is a leading symptom and faecal matter
         tumour etc                                                  or bile is always present in the stool.
                                                               Henoch-Schonlein purpura (HSP):
Pathology
                                                                   Associated with characteristic rash and abdominal
An intussusception has                                               pain but intussusception may also occur.
 The entering or inner tube (intussusceptum)
                                                              In cases of protruding mass from anus –
 The returning or middle tube
 The sheath or outer tube (intussuscipiens)                    Rectal prolapse
 Apex: the part which advances                              Treatment
 The mass: the intussusception
                                                              Conservative treatment
 The neck: the junction of the entering layer with the
    mass                                                      Hydrostatic reduction with water enema or barium
 The inner tube is prone for strangulation                  enema: repeated enemas are given with saline till the
                                                              flatus and faeces is passed with force
Classification                                                Contraindications
   Ileoileal - 5%
                                                                 In the presence of complete obstruction
   Ileocolic - 77 %
                                                                 Peritonism or
   Ileo-ileo-colic - 12 %
                                                                 A prolonged history (more than 48 hours)
   Colocolic - 2 %
   Multiple - 1%                                            Surgery
   Retrograde - 3%                                          Indication
   The colo-colic variety is common in adults                  Failed or contraindicated conservative treatment
Yogi Ram’s lectures on Surgery
                                                            Intestinal obstruction – specific diseases and management 9

Procedure                                                             Operative treatment
Reduction is achieved by squeezing the most distal part of              To knead the tangled mass into the caecum
the mass in a cephalad direction. The bowel should not be               Enterotomy and removal of mass of worms (closure of
pulled. The viability of bowel should be checked after                    bowel wall is done with non-absorbable sutures as
reduction.                                                                round worms are known to migrate through the suture
The underlying cause requires appropriate treatment.                      line)
In the presence of an irreducible or gangrenous                        For perforation: resection of the diseased segment +
intussusception, the mass is excised and anastomosed                      removal of worms from peritoneal cavity and
Recurrent intussusception                                                 peritoneal toilet
It is rare (5 per cent of idiopathic cases).                          Prognosis
Treatment                                                             Mortality is around 10% and occurs usually in cases
                                                                      presenting late.
Anchorage of the last part of the terminal ileum to the
ascending colon is performed.                                         INTESTINAL OBSTRUCTION IN ADULTS
Ascariasis                                                            Adhesions and bands
It may cause ileal obstruction, particularly in children.
                                                                      These are the commonest cause of intestinal obstruction in
Pathology                                                             adults.
Bolus of worms in the lumen of the bowel can lead to                  Adhesions
partial or complete intestinal obstruction. Sometimes, the
worms can also cause perforation of the bowel.                        Causes
Clinical features                                                        Post inflammatory
Types of presentation                                                       Acute peritonitis
                                                                            Tuberculosis
 Subacute intestinal obstruction
                                                                            Crohn’s disease
 Acute intestinal obstruction
                                                                         Postoperative
Sub acute obstruction                                                       Introduction of foreign material
  Recurrent attacks of colic, vomiting, mild fever with                       Unabsorbable glove powder (talc, starch),
    or without constipation or diarrhoea                                             silk sutures, gauze
 Mild to moderate abdominal distension                                    Postoperative adhesions usually involve the lower
Investigations                                                                 small bowel
 Barium follow-through                                                    Operations for appendicitis and gynaecological
                                                                               procedures are the most common conditions and
Acute obstruction                                                              are an indication for early intervention
It frequently follows antihelminthic therapy. It presents as             Post radiation
–                                                                        Drugs: practolol
 Features of obstruction in a debilitated child with
      toxaemia
                                                                      Pathology
 Eosinophilia                                                       Any peritoneal irritation  local fibrin production 
 If perforation has occurred, it presents as peritonitis            adhesions between opposed surfaces.
                                                                      Early fibrinous adhesions may disappear when the cause is
Investigations
                                                                      removed or they may become vascularised and replaced by
 Plain X-ray abdomen                                                mature fibrous tissue
 Evidence of obstruction
                                                                      Classification
 Features of perforation, if present
                                                                       According to time of onset
Treatment
                                                                         Early (fibrinous)
   Conservative treatment + antihelminthics
                                                                            Occur during days 1 -5
      Drip and suction + albendazole/ mebendazole, /
                                                                            Majority are treated conservatively
          ivermectin
                                                                         Late (fibrous)
      The antihelminthics are given after the acute colic
          and toxicity has disappeared. If given during                     Occur after 7 days
          colic, the paralysed worms may get bundled and                    Surgery may be needed
          precipitate acute obstruction                               Prevention
   If no relief, laparotomy is performed

                                                                                              Yogi Ram’s lectures on Surgery
10 Intestinal obstruction – specific diseases and management

The following factors may limit adhesion formation:              It presents as acute intestinal obstruction and the
 Good surgical technique                                       preoperative diagnosis is difficult.
 Washing of the peritoneal cavity with saline to remove        Treatment
    clots, etc. at the end of operation
 To cover anastomosis and raw peritoneal surfaces                 Laparotomy and release of the constricting agent
 Usage of soluble glove powder (Potassium bitartrate)             Some times, major blood vessels run in the edge of the
                                                                      constriction ring, e.g., the foramen of Winslow,
Bands                                                                 mesenteric defects and the
                                                                      paraduodenal/duodenojejunal fossae.
Causes                                                              In these cases, the constricting ring should not be cut.
   Congenital, e.g., obliterated vitellointestinal duct             The distended loop in such circumstances must first be
   Conversion of adhesions to bands                                 decompressed and then reduced.
Clinical presentation                                            Stricture
   Sub acute or acute intestinal obstruction
                                                                 Causes
   Due to kinking, torsion or entrapment
                                                                    Tuberculosis
Treatment                                                           Crohn's disease
   Initial management:                                            Malignant strictures
      Conservative treatment, which should not be                    Lymphoma (common)
          prolonged beyond 72 hours.                                   Carcinoma and sarcoma (rare)
   Surgery
                                                                 Clinical presentation
      The responsible band or adhesion is lysed and the
          remaining is left in situ unless severe angulation     Usually as subacute or chronic intestinal obstruction
          of intestine is present. Division of these adhesions   Surgical management
          will only cause further adhesion formation.
                                                                    Strictureplasty
      The bare area should be covered with omental
                                                                    Resection and end to end anastomosis
          grafts or Lembert’s suture
                                                                    Wide resection in malignant strictures
Treatment of recurrent intestinal obstruction
due to adhesions                                                 Bolus obstruction
   Repeat adhesiolysis (enteroclysis) alone                    Causes
   Noble's plication operation
                                                                    Food,
   Charles-Phillips transmesenteric placation
                                                                    Gallstones,
   Intestinal intubation
                                                                    Trichobezoar,
Internal hernia                                                     Phytobezoar,
                                                                    Stercoliths and
Sites of internal hernia                                            Worms.
   Defects in the peritoneal cavity                            Gallstone obturation
      The foramen of Winslow
      Hole in the mesentery
                                                                 Pathology
      Hole in the transverse mesocolon                         These occur due to cholecysto-duodenal fistula. The
      Defects in the broad ligament                            impaction occurs at 60 centimetres proximal to the
      Congenital or acquired diaphragmatic hernia              ileocaecal valve.
   Retroperitoneal fossae                                      Clinical features
      Duodenal retroperitoneal fossae                          Recurrent attacks of subacute obstruction due to
           Left paraduodenal and                               incomplete or a ball-valve effect.
           Right duodenojejunal
                                                                 Investigations
   Caecal retroperitoneal fossae
      Superior                                                    Plain X ray abdomen:
      Inferior and                                                   Evidence of small bowel obstruction
      Retrocaecal                                                    Air shadow in the biliary tree
   Intersigmoid fossa                                                The stone may or may not be visible
Clinical presentation                                            Treatment
                                                                    Laparotomy + enterotomy
Yogi Ram’s lectures on Surgery
                                                           Intestinal obstruction – specific diseases and management 11

        The region of the gall bladder should not be                     caecostomy.
          explored for fear of breaking open the fistula                 If the caecum is ischaemic or gangrenous, a right
          between the gall bladder and duodenum with                       hemicolectomy is done
          associated bile leak                                        Sigmoid volvulus
Trichobezoars and phytobezoars                                        Incidence
These are firm masses of hairballs and undigested
                                                                      Rare in Europe and the USA but more common in Eastern
fruit/vegetable fibre, respectively.
                                                                      Europe, Africa and India
Treatment
                                                                      Predisposing factors
If possible, the lesion may be kneaded into the caecum, or
otherwise enterotomy is required.                                        High residue diet and chronic constipation.
                                                                      Pathology
Volvulus
                                                                      Rotation of sigmoid loop occurs in an anticlockwise
It is a twisting or axial rotation of a portion of bowel.             direction.
When complete, it forms a closed loop obstruction with
ischaemia of the loop.
                                                                      Clinical features
                                                                         Features of large bowel obstruction
Pathogenesis of volvulus                                                 Abdominal distension is an early and progressive sign
Volvulus of the small intestine                                       Investigation
 In neonates, it presents like volvulus of midgut
                                                                         Plain X ray abdomen
 In adults, it usually occurs in the lower ileum.
                                                                            Massive colonic distension.
Causes in adults                                                            Dilated loop of bowel running diagonally across
   Primary or idiopathic (in Africans, particularly                          the abdomen with two fluid levels, one in each
     following consumption of a large volume of vegetable                      loop of bowel (Coffee - seed appearance)
     matter)                                                          Treatment
   Secondary
                                                                      Non-operative method
      Adhesions to the parities or uterus and Fallopian
          tubes                                                        Untwisting the twist by flexible sigmoidoscopy or
                                                                         rigid sigmoidoscopy
Treatment
                                                                      Surgery
   Reduction of the twist and managing the underlying
     cause.                                                              Laparotomy, with untwisting of the loop and per-anal
                                                                           decompression
Caecal volvulus                                                          When the bowel is viable,
Pathology                                                                   Fixation of the sigmoid colon to the posterior
                                                                               abdominal wall is done
   It may occur as part of volvulus neonatorum or de
     novo                                                                   Resection of the sigmoid loop with end-to-end
                                                                               anastomosis is done if conditions are favourable.
   It twists clockwise
                                                                         Suspicion of impending gangrene / gangrene:
Clinical presentation                                                       Paul-Mikulicz procedure / Hartmann's procedure
It presents as a palpable tympanic swelling in the midline                     or
or left side of the abdomen associated with features of                     Primary sigmoid colectomy and anastomosis, if
intestinal obstruction.                                                        the conditions are favourable
Investigations                                                        Compound volvulus (ileosigmoid knotting)
   Plain X ray abdomen                                                 Rare
      Ileal loops and occasionally a distended caecum                  It is twisting of the ileum around the sigmoid colon
         in the centre of abdomen                                          resulting in gangrene of both segments of bowel.
   Barium enema                                                        X ray abdomen
      Absence of barium in the caecum and a bird beak                     Distended ileal loops with distended sigmoid loop
         deformity.                                                      Surgery
Treatment                                                                     Decompression, resection and anastomosis
Surgery
                                                                      INTESTINAL OBSTRUCTION IN THE
   Reduction of the volvulus and fixation of the caecum
     to the right iliac fossa (caecopexy) and/or a                    ELDERLY

                                                                                              Yogi Ram’s lectures on Surgery
12 Intestinal obstruction – specific diseases and management

The intestinal obstruction in the elderly manifests as                It may present as chronic intestinal obstruction or as acute
chronic or as acute on chronic intestinal obstruction.                on chronic intestinal obstruction
                                                                       Constipation appears first
Causes                                                                 It is initially relative and then absolute
   Organic:                                                          Peripheral abdominal distension with greatest
      Intraluminal                                                      distension in the right iliac fossa (due to caecum)
          Faecal Impaction                                           Later, pain
      Intramural                                                     Vomiting is a late feature
          Cancer                                                     Per rectal examination: faecal impaction or a tumour
          Diverticulitis                                                may be felt
          Strictures (Crohn’s disease, ischaemia,                   Investigations
              tuberculosis)
          Anastomotic stenosis                                         Plain X-ray abdomen:
      Extramural                                                          Gas shadows in the colon.
          Adhesion (small bowel only)                                  Water soluble contrast enema
          Metastatic deposits                                             Filling defect in the colon can be detected
          Endometriosis
   Functional
                                                                      Treatment
      Hirschsprung's disease                                           Depends on the underlying cause
      Pseudo-obstruction
                                                                      Summary of management of acute on
Clinical features                                                     chronic intestinal obstruction

                                            Acute on chronic obstruction

                                             X ray &/ water soluble contrast enema


                                    Dynamic (organic)                       Adynamic (functional)


                            Resectable growth &          Inoperable growth or   Resectable growth &
                                 Fit patient                 unfit patient          unfit patient

                             •Rt colon = rt                                Rt colon = ileo-transverse
                                                            •Bypass
                             hemicolectomy                                 colostomy
                                                            •Colostomy
                             •Lt colon =                                   Lt colon =
                                                            •Caecostomy
                             resection, after on                           •Paul-Mickulicz or
                                                            •Ileostomy
                             table lavage                                  Hartman’s or colostomy
                                                                           with mucus fistula
                                                                          plexus and the submucous (Meissner’s) plexuses]
ADYNAMIC OBSTRUCTION                                                                              
                                                                       Accumulation of fluid and gas within the bowel (III space
Causes                                                                                          loss)
   Paralytic ileus                                                                               
   Pseudo-obstruction                                                      Dehydration, shock, and abdominal distension
   Mesenteric vascular insufficiency
                                                                      Types
Paralytic ileus                                                          Postoperative:
                                                                            After any abdominal procedure
Definition                                                                  Self-limiting with a variable duration of 24-72
 Failure of transmission of peristaltic waves secondary to                     hours
neuro- muscular failure [i.e. in the myenteric (Auerbach’s)                 Prolonged in the presence of hypoprotinaemia or
Yogi Ram’s lectures on Surgery
                                                         Intestinal obstruction – specific diseases and management 13

         metabolic abnormality                                            Myxoedema
   Infection:                                                           Uraemia
      Localized or generalised ileus                                 Severe trauma
   Reflex ileus                                                      Shock and septicaemia
      Following fractures of the spine or ribs                       Retroperitoneal collections of blood, urine, and
      Retroperitoneal haemorrhage                                      enzymes (pancreatitis)
      Application of a plaster jacket                                Secondary gastrointestinal involvement
    Metabolic                                                           Scleroderma
      Uraemia                                                           Chagas' disease
      Hypokalaemia or hyperkalaemia                                  Drugs
Clinical features                                                         Tricyclic antidepressants
                                                                          Phenothiazines
Paralytic ileus should be suspected in postoperative period
                                                                          Levodopa
after 72 hours, if –
                                                                          Laxatives
 Bowel sounds and pain are absent (silent abdomen)
 Flatus is not passed                                             Small intestinal pseudo-obstruction
 Copious naso-gastric aspirate /copious effortless                Clinical features
     vomiting
                                                                       Recurrent subacute obstruction.
 Abdominal distension which is tympanitic
                                                                       The diagnosis is made by the exclusion of a
Investigations                                                           mechanical cause.
   Plain X ray abdomen                                            Treatment
      Multiple air fluid levels
                                                                       Treat the cause
   Electrolyte estimation
                                                                       Prokinetics
   Check for anastomotic leak
                                                                          Cisapride
Management                                                                Erythromycin
Prevention                                                          Colonic pseudo-obstruction
   During surgery, the bowel should be handled gently             Types of manifestation
     and the peritoneal cavity should be free from blood
     clots before closure                                              Acute (Ogilvie syndrome).
   In the post-operative period, naso-gastric suction and            Chronic
     restriction of oral intake is advised until return of          Clinical features and plain X ray abdomen
     bowel sounds and passage of flatus                             They are similar to chronic dynamic obstruction.
   Maintenance of electrolyte balance
                                                                    Investigations
Conservative management
                                                                       Colonoscopy or water-soluble contrast enema.
   Management of the cause and drip and suction
   There is no place for peristaltic stimulants                   Treatment
   In prolonged cases, look for anastomotic leak or for              Cisapride
     collections in the peritoneal cavity                              Colonoscopic decompression.
   In resistant cases, organic obstruction should be                 When colonoscopy fails or unavailable, a tube
     excluded and if in doubt, laparotomy is done                        caecostomy is done
Pseudo-obstruction                                                  Treatment of persistent disease
                                                                       Subtotal colectomy and ileorectal anastomosis.
Definition
Pseudo obstruction is the obstruction, of the colon due to          Acute mesenteric ischaemia
neuropathy or myopathy in the absence of a mechanical
                                                                    Classification
cause. (C.f.: in paralytic ileus, the whole bowel is paretic
and in pseudo-obstruction, the proximal normal bowel                   Acute with or without venous occlusion
shows features of obstruction)                                         Chronic
                                                                          Central
Causes
                                                                          Peripheral
   Idiopathic
   Metabolic                                                      Causes
      Diabetes                                                       Obstruction of superior mesenteric vessels


                                                                                             Yogi Ram’s lectures on Surgery
14 Intestinal obstruction – specific diseases and management


      Embolism (more common)                                           may be tried
      Thrombosis                                              Treatment of large bowel infarction
   Obstruction of inferior mesenteric artery (it is usually
     silent owing to a better collateral circulation.)             Rare.
   Sources for the embolism                                      If presents with gangrene, resection and anastomosis
                                                                     or colostomy is done
      Left atrium associated with fibrillation
      A mural myocardial infarct                              Ischaemic colitis
      Atheromatous plaque
      Aortic aneurysm                                         Aetiology
      And a mitral valve vegetation associated with              Chronic ischaemia
          endocarditis
   Sources for thrombosis
                                                                Pathology
      Atherosclerosis                                         It is commonly seen in the splenic flexure
      TAO                                                     Classification
      Contraceptive pill
                                                                   Gangrenous
      Sickle cell disease
                                                                   Stricturing
      Primary thrombosis of the superior mesenteric
                                                                   Transient
          veins
                                                                Clinical features
Pathology
                                                                   Lower abdominal pain and the passage of blood per
   Depends upon the site of occlusion – main vessel or a
                                                                     rectum.
     branch and associated venous involvement
   If the main vessel of superior mesenteric artery is        Investigations
     involved, the infarction extends from just distal to the      Mesenteric angiogram
     DJ flexure to the splenic flexure or terminal ileum
     depending upon marginal artery                             Treatment
   If a branch is involved, the area of infarction is less       Depends upon the type and cause of vascular
   Blood-stained fluid exudes into the peritoneal cavity           occlusion
     and into bowel lumen of the infarcted bowel
                                                                COLOSTOMY
Clinical features
   Sudden and severe umbilical pain in a patient with         Types
     atrial fibrillation or atherosclerosis
                                                                   Temporary
   Passage of altered blood per rectum
                                                                      Congenital defects: imperforate anus
   Hypovolaemic shock
                                                                      Traumatic: perforation of rectum
   Abdominal tenderness with rigidity later
                                                                      Inflammatory: high level fistula in ano, stricture
Investigation                                                            rectum, radiation proctitis
   Total white cell count: neutrophil leucocytosis                  Neoplastic diseases: carcinoma rectum
   Plain X-ray abdomen:                                          Permanent
      The presence of gas bubbles in the mesenteric                 Inoperable carcinoma rectum,
         veins is rare but pathognomonic                              As part of operative procedure (APR)
   Superior mesenteric angiogram                              Classification
Treatment
   Resuscitation
                                                                Depending upon the site of the anastomosis
   In the early embolic cases (rarely diagnosed)                 Pelvic (sigmoid) colostomy
      Embolectomy via the ileocolic artery or                    Transverse colostomy
          revascularisation of the superior mesenteric artery   Depending upon the procedure
          may be considered.
                                                                   Loop colostomy
   In gangrenous cases
                                                                   Double barrel colostomy
      All affected bowel should be resected and
          followed by total parenteral nutrition                   End colostomy
      Anticoagulants are given in the postoperative           Procedure of pelvic colostomy (loop
          period                                                colostomy)
      In selected cases, small bowel transplantation
Yogi Ram’s lectures on Surgery
                                                        Intestinal obstruction – specific diseases and management 15




A left iliac muscle cutting incision is made and a loop of         Closure of the double barrel colostomy
pelvic colon identified. The left paracolic gutter is              When it is desired to close the colostomy, an enterotome is
obliterated at the side of pelvic colon to prevent the             passed into the colostomy openings and is tightened every
herniation of bowel by a continuous absorbable suture.             day to gradually crush the intervening septum. The septum
Colon loop is brought out and kept in position with the            after crushing breaks open making a communication
help of rubber tubing and glass rod or a bridge of skin. The       between the two loops of the barrel. Then, the external
wall of the loop, which is brought out is sutured to               opening of the colostomy along with the surrounding skin
abdominal wound. The colon is opened on 2nd day and the            is excised; the opening in the colon closed and the closed
edges of the colostomy are sutured to adjacent skin                loop is pushed inside. The abdominal wall is closed.
margins. The bridge is removed after 7 days
                                                                   End colostomy (permanent colostomy)
Double barrel colostomy (Paul -
Mickulicz’s procedure)                                             The distal end of the bowel is brought out and sutured to
                                                                   the skin after slightly everting its margins. E.g., following
The procedure is same as colostomy, but the colon is made          abdomino-peroneal resection, and following Hartman’s
into a double barrel shape by making a seromuscular                operation
suture to the adjacent loops of bowel.
The advantage of this procedure is to close the colostomy
after the need, by extra-peritoneal closure with the help of
an enterotome.




                                                                                            Yogi Ram’s lectures on Surgery
16 The rectum and the anus


Chapter 3

             THE RECTUM AND THE ANUS
EMBRYOLOGY                                                      Mucosa of the rectum and the anal canal
Rectum is developed from entodermal cloaca, which is              Rectal mucosa
continuous with the hindgut*. The anal canal is developed            It is pale pink in colour
from the proctodeum, which fuses with the rectum at the          Anal mucosa varies:
dentate line. (* The recto vesical septum divides the cloaca         Its colour gradually changes from red, plum, and
into anterior urinary system and posterior rectum)                       white to black at its lower end.
                                                                     The anal mucosa is thrown into longitudinal folds
ANATOMY                                                                  called as anal columns (columns of Morgagni).
                                                                         The lower ends of these columns are connected
Rectum                                                                   by a wavy mucous membrane called as dentate
It extends from rectosigmoid junction at the promontory of               line. The space above this dentate line is called as
the sacrum to the anorectal ring.                                        anal crypts. Into these crypts, the ducts of anal
                                                                         glands open.
Anal canal                                                      Anal glands
                                                                They are situated between longitudinal coat and internal
                                                                sphincter with their opening at the base of the columns of
                                                                Morgagni in the anal crypts.
                                                                Blood supply of the rectum and the anal canal
                                                                Arterial supply
                                                                   Superior rectal (from inferior mesenteric)
It extends from the anorectal ring to the anal verge
                                                                   Middle rectal (from internal iliac)
(surgical anal canal) and it is three centimetres in length.
Anatomical anal canal (1 – 1.5 cms) extends from dentate           Inferior rectal (from internal pudendal, branch of
line to anal verge (developed from proctodeum).                      internal iliac)
The anal canal has –                                            Venous drainage
 Sphincters                                                   The submucous vasculature drains into –
      Extrinsic sphincter (levator ani muscle)                 The venous plexus above the dentate line drains into
      Intrinsic sphincters                                         superior haemorrhoidal vein  inferior mesenteric
 Anal mucosa                                                       vein (portal)
 Submucous vasculature                                         The plexus below the dentate line drains into inferior
Extrinsic sphincter – Levator ani                                    haemorrhoidal vein internal pudendal vein 
                                                                     internal iliac vein (systemic)
It forms pelvic diaphragm with ischio-coccygeus and gives       Hence, there is a communication between portal and
support to anorectum and acts as an extrinsic sphincter,        systemic circulations in the sub mucosa of the anal canal
especially with its inner most bundle, puborectalis sling.      and the rectum.
Intrinsic sphincters
The rectum has the same muscle coats as colon, but the
                                                                FUNCTIONS OF THE ANAL CANAL
anal canal has a unique system of muscles to provide the           Continence for faeces and flatus: this function is
continence for flatus, fluid and faeces.                             contributed by
 External sphincter                                                 Sphincters of anal canal: mostly by the ano -
 Internal sphincter (the thickened circular muscle)                    rectal ring, and the external sphincter and to a
 Longitudinal coat in between the sphincters binding                   smaller extent by the internal sphincter
     them together                                                    Angulation of ano-rectal angle: the angle between
 Anorectal ring, the fused upper part of internal,                     the rectum and anal canal is 1200, which is
     external sphincters with insertion of levator ani muscle            maintained by puborectalis sling
      It is the most important muscle of the anal canal          Sensory perception by mucosa for flatus, fluid and
         for maintaining continence                                  faeces
Yogi Ram’s lectures on Surgery
                                                                                          The rectum and the anus 17


LAND-MARKS IN THE ANATOMY OF                                                      vagina (in an anteverted uterus, the
                                                                                  cervix is felt as rounded mass and may
ANAL CANAL                                                                        be mistaken for a tumour)
   Anorectal ring                                                           Laterally, ischiorectal fossa, levator ani,
   Dentate line (it is the union of embryonic ectoderm                          lateral wall of the pelvis, pelvic
     with entodermal gut and resides at 1 – 1.5 centimetres                       appendix, if inflamed
     from anal verge.)                                                        Posteriorly, sacrum and coccyx and the
   Anal verge                                                                   ano-coccygeal raphe
                                                                          The finger stall is examined after removing
Importance of dentate line                                                   the finger from the rectum for any blood
                                                                             stains or mucus discharge
Dentate line is the line of fusion of proctodeum with post-
                                                                   Proctoscopy
allantoic hindgut
                                                                   Sigmoidoscopy
 Below dentate line –
                                                                   Endoluminal ultrasonography
      Lesions are painful because of the somatic
          innervation                                              Transanal ultrasonography
      Epithelium is squamous                                     Defecography and rectal manometry
      Drains into systemic venous system                      CONGENITAL ABNORMALITIES
 Above dentate line –
      Lesions are painless because of autonomic               Imperforate anus
          innervation
      Epithelium is cuboidal                                  Syn: agenesis or atresia of rectum and anus
      Drains into portal system                               Incidence
INVESTIGATIONS OF THE ANORECTAL                                    One in 4500 births
DISEASES
                                                                Types
   Per rectal examination:
      This is an important method of examination of the          High abnormalities: termination of bowel is above
         anal and rectal diseases                                    pelvic floor. They are difficult to treat and are usually
      Position of the patient: the patient is examined in          associated with urinary fistula.
         one of the following positions –                             Anorectal agenesis
          Left lateral                                              Rectal atresia
          Knee-chest                                                Cloaca
          Lithotomy                                              Low abnormalities: termination of bowel is below
      Procedure:                                                   pelvic floor and they are easy to treat
          A gloved index finger with lubricating jelly is           Covered anus
              placed on the anterior edge of the anal                 Ectopic anus
              opening and is slightly slided down into the            Anal stenosis
              anal opening. (The finger should not be thrust          Membranous stenosis
              into the anal canal, as it can hurt the patient   Covered anus
              and make him contract the sphincters)
                                                                   The underlying anal canal is covered by a bar of skin
          The contents in the lumen are examined, the
                                                                     with a track opening at perineal raphe. The track is
              walls of the anal canal and rectum are
                                                                     seen filled with the meconium.
              examined for any induration, ulcer, plaque or
              a mass and if any abnormality is noted, their     Treatment
              characters are noted (site, size, shape,             Opening of the track and dilatation of the anus
              surface, surroundings, margins, consistency
              and the mobility over the mucosa and              Ectopic anus
              underlying structures)                               Anal orifice is situated anteriorly opening into vulva
          Later, the structures outside the rectum are             or vagina in girls and in the perineum of boys
              examined –
                                                                Treatment
               Anteriorly, in males, the prostate,
                   seminal vesicles, base of the bladder and       Plastic cut-back operation
                   recto-vesical pouch. In females, recto-      Anal stenosis
                   vaginal pouch and posterior wall of the
                                                                   Stenosis of anal canal at dentate line

                                                                                          Yogi Ram’s lectures on Surgery
18 The rectum and the anus

Treatment                                                        Sacro-coccygeal teratoma
   Dilatation                                                     It is the commonest large tumour in the first three
Membranous anus                                                       months of life. It arises from the site of the primitive
   Anus is covered with a thin membrane at the dentate              knot (an area of a group of totipotent cells). It arises
     line                                                             between sacrum and rectum and attached to coccyx or
                                                                      last piece of sacrum. It may attain very large size. It is
Treatment                                                             common in females.
   Incision of the membrane                                       Treatment: excision soon after birth
Anorectal agenesis                                               Post anal dermoid
   Agenesis of the annual canal and the rectum,
                                                                 It is a simple form of teratoma
     associated with a fistula into the bladder or vagina
                                                                 Clinical features
Rectal atresia
                                                                 It is commonly seen in adults. It presents as a post anal
   Anal canal and colon ends blindly as a stricture with       cystic swelling. Usually, it has a sinus communicating with
     out development of the rectum                               the mass.
Treatment                                                        On per rectal examination, the cyst is palpable on the
   Excision of stricture and anastomosis                       posterior wall of the anal canal.

Cloaca                                                           Differential diagnosis
   Occurs in females. Bowel, urinary and genital tracts           Pilonidal sinus: in this condition, the track lies
     open into common cavity                                          posterior to the sacrum
                                                                 Treatment
Investigations of imperforate anus
                                                                    Excision of the cyst and the track
   Every new-born baby’s temperature should be
     recorded by a rectal thermometer, so as to enable the       INFLAMMATORY DISEASES OF THE
     attending nurse to identify the abnormality at the          ANORECTUM
     earliest, as the early treatment gives a good prognosis
     to the child                                                   Acute inflammation
   1) Invertogram: it is a plain X ray of the abdomen                Amoebic dysentery
     taken in an inverted posture of the child.                        Bacillary dysentery
      Child is held upside down for 3 – 4 minutes and a           Chronic inflammation
          radiograph is taken after keeping a lead shot at the         Tuberculosis
          site of the anus. Normally, air collects in the              Syphilis
          colon six hours after birth. This air now fills the          LGV
          rectum in the inverted posture and the distance              Gonorrhoea
          between the anal orifice and the gas shadow can              Schistosomiasis
          be observed on a plain X ray of the abdomen.
      If the distance between the lead shot and the gas        FISSURE IN ANO
          in the rectum is more than 2.5 centimetres, or if
          the gas shadow is above the pubo coccygeal line        Definition
          (line joining the upper border of coccyx to upper      It is a crack or a fissure in the anoderm (anal skin below
          border of pubis), it is a high abnormality.            the dentate line)
   2) Urine for coliforms: they are present in high
     abnormalities, because of fistula between the rectum        Pathology
     and the bladder
                                                                    It is due to hypertonic anal sphincter and decreased
Treatment of high anomalies                                           anodermal blood flow
One of the following procedures is followed –
                                                                 Pathogenesis
 Laparotomy + division of vesico-colic fistula +
    transverse colostomy immediately after the birth of the      Passage of hard faecal matter through the anal canal with a
    child                                                                           hypertonic sphincter
 And pull-through operation at the age of two years.                                       
 Laparotomy and pull-through in one stage                                 Tear of anal mucosa causing fissure
 Colostomy only for cloacal abnormality                                                    
                                                                       Intense spasm of underlying internal sphincter
Yogi Ram’s lectures on Surgery
                                                                                       The rectum and the anus 19


                                                                Haemorrhoids
          Severe pain with perpetuation of fissure
                                                              Treatment
Site
   In males: 90% occur on the posterior midline in the      Treatment of acute fissure
     mucosa of the anal canal below the dentate line             Local anaesthetic ointment (5% lignocaine)
   In females, 60% occur on the posterior midline and          Stool softeners
     40% on the anterior midline of the anal canal below            Fibre diet
     the dentate line                                               Liquid paraffin or lactulose syrup
      The anterior fissure is relatively more common in        Antibiotics and metronidazole
          females due to the lack of the support by the          If pain is not relieved –
          stretched perineal body in multiparous women              Anal dilation with graduated anal dilators
Parts                                                               Sphincter dilatation under general anaesthesia
   Fissure or crack in the anoderm exposing the fibres of   Treatment of chronic fissure
     the internal sphincter in its floor
                                                              Conservative
   Anal polyp: hypertrophic granulations covered with
     anal mucosa at the upper part of the fissure                0.2% glyceryl trinitrate ointment to relieve the
   Sentinel pile: it is a hypertrophic granulation mass          sphincter spasm, which is the cause for the fissure
     covered with skin and is situated at the lower end of       Recurrence is common
     the fissure. It appears like guarding the fissure and    Surgery
     hence, is called as sentinel (= guard) pile
                                                              Indications
Clinical features                                              Deep chronic fissures
                                                               Fissure with sentinel pile or anal papilla
   Age: can occur at any age
                                                               Fissure with fistula
Clinical presentation                                         Contra-indications
   Acute                                                     Elderly patients with decreased anal sensation
   Chronic
                                                              Procedure
Acute                                                          Sphincterotomy (incision of internal sphincter) to
   Severe excruciating pain following defecation               relieve the spasm of the sphincter, which is the cause
   Bleeding: staining of faecal matter with blood or           for the persistence of the fissure. It is done by two
     passage of fresh fluid blood after defecation               methods –
Chronic                                                           Dorsal sphincterotomy
                                                                  Lateral sphincterotomy (Notaras)
   Mucoid discharge                                                  Open
   Persistent pain with acute exacerbations                          Closed
Complications                                                 Dorsal sphincterotomy
   Abscess                                                     Incision is made through the floor of the ulcer till the
                                                                   white longitudinal coat is seen, sentinel pile excised
   Fistula in ano
                                                                   and drainage of abscess or fistulectomy is done.
Differential diagnosis                                        Complication
                                                                Soiling of clothes post operatively because of the key-
   Syphilis
                                                                  hole deformity of the posterior wall of the terminal
   Tuberculosis
                                                                  part of the anal canal
   Proctalgia fugax:
      No lesions, but severe, spasmodic, episodic pain      Lateral submucous sphincterotomy (Notaras)
          in the rectum                                       This procedure is performed by two methods –
   Crohn’s disease                                           1) Closed method: a knife is passed through the
      The fissure may be lateral and has a shiny skin tag       perianal skin between internal and external sphincters;
   Carcinoma of the anal canal                                  the edge of the knife is turned internally and cut
   Fistula in ano                                               through internal sphincter. The incision should not
                                                                  exceed beyond the dentate line and external sphincter
Differential diagnosis of sentinel pile                           is completely spared
                                                               2) Open method: an incision is made at the perianal

                                                                                       Yogi Ram’s lectures on Surgery
20 The rectum and the anus


     area, just by the side of the anal orifice. The incision is           Upwards into the intersphincteric space as
     deepened and the internal sphincter below the level of                  intersphincteric abscess
     dentate line is hooked on to an artery forceps, ligated               From the ischiorectal space, it may spread
     and cut. The mucosa is not injured in this procedure                    upwards, especially when abscess cavity is
     and so, the faecal soiling does not occur with this                     probed without anesthesia, through the levator ani
     procedure.                                                              muscle into the Pelvirectal space as pelvi-rectal
                                                                             abscess
ANO - RECTAL SUPPURATION
                                                                   Sub cutaneous abscess
Definition                                                            Incidence: 60%
Infection of perianal and perirectal spaces is called as ano-      Causes
rectal suppuration                                                    Suppuration of anal gland
Peri-rectal and anal spaces                                           Infected thrombosed external pile
                                                                      Folliculitis
1) Intersphincteric
2) Subcutaneous
                                                                   Treatment
3) Ischiorectal                                                       Incision and drainage at the earliest
4) Pelvirectal                                                     Ischiorectal abscess
5) Submucous
                                                                      Incidence: 30%
Aetiology                                                          Causes
   Anal gland suppuration: it can produce abscess in the            Spread from suppurated anal gland
     following peri anal spaces                                       Rarely due to haematogenous or lymphatic spread
      Subcutaneous (perianal)                                    Pathology
      Submucous
      Intersphincteric                                              It may communicate with the opposite side via the
      Ischio-rectal (perianal)                                        post sphincteric space  horseshoe abscess and fistula
      Pelvi-rectal                                               Treatment
   Non specific infections                                          Early operation without waiting for fluctuation by
      Subcutaneous (due to infected perianal                          cruciate incision
          haematoma or perianal folliculitis)                         Examined for a fistulous communication and if
      Submucous (infection following injection for                    present, treated like fistula (done only under spinal or
          haemorrhoids)                                                 general anaesthesia)
      Fissure abscess (subcutaneous abscess due to
          infected fissure)                                        Submucous abscess
   Specific infection, e.g., tuberculosis, actinomycosis            Incidence: 5%
   Infected malignant lesions                                    Causes
   Immuno suppression
                                                                      Infected haemorrhoidal injection
      HIV
                                                                      Extension of anal gland suppuration
      Diabetes mellitus
                                                                   Treatment
Pathogenesis of abscess from the anal
                                                                      Incision through the proctoscope
gland suppuration
                                                                   Pelvi rectal abscess
   The anal gland is situated in the intersphincteric plane         Incidence: less than 5%
     with its duct opening into the anal crypts at the dentate
     line                                                          Causes
   If it is suppurated, the pus will spread from it in the          Extension of suppurated intersphincteric abscess,
     path of least resistance –                                         usually due to over-enthusiastic probing
      Downwards in the intersphincteric plane to the                As a form of pelvis abscess secondary to appendicitis,
           skin and presents as subcutaneous abscess                    parametritis, diverticulitis, salpingitis, and Crohn’s
      Laterally through the external sphincter into the               disease
           ischiorectal space as ischiorectal abscess
                                                                   Treatment
      Medially into the submucosal space as
           submucosal abscess                                         The abscess opened into the rectum

Yogi Ram’s lectures on Surgery
                                                                                     The rectum and the anus 21

Clinical feature of perianal suppurations                       3) Low anal
                                                                4) High anal
General
                                                                5) Pelvi-rectal
   Fever, malaise, chills
                                                             Park’s classification (depending upon the
Local                                                        position of the track in relation to the
   Throbbing pain aggravated by dependent posture          sphincters)
   Indurated, brawny mass in the perianal area or in the
                                                                1) Inter-sphincteric fistula: the track passes between
     rectal wall depending upon the site of the abscess.
                                                                  the internal and external sphincters with an internal
Treatment of perianal suppuration                                 opening, usually at the dentate line
   Analgesics and antibiotics                                 2) Trans-sphincteric fistula: the track passes across
   Incision and drainage:                                       both the sphincters, with an internal opening usually at
      Indication: presence of brawny induration (should         the dentate line
          not wait till the fluctuation appears)                3) Supralevator fistula: the track passes through the
      If delayed, the abscess spreads upwards.                  levator ani muscle and opens above the anorectal ring
                                                                  into the rectum
Sequelae                                                        4) Supra sphincteric fistula: the track passes out side
   Fistula in ano                                               the external sphincter through the levator ani muscle
                                                                  and then passes down above the ano-rectal ring as an
FISTULA IN ANO                                                    inter-sphincteric fistula and opens at the dentate line
Definition                                                   Classification depending upon the relation of
                                                             the track and internal opening to the anorectal
Fistula = flute
                                                             ring
A track lined by granulation tissue connecting two
                                                                High level (above ano - rectal ring)
epithelial surfaces
                                                                Low level (below ano - rectal ring)
(Sinus = bay)
                                                             Clinical features
Aetiology of fistula in general
                                                               Persistent sinus with sero-purulent discharge
   Presence of foreign body in the depth of the wound          perianally with or with out internal opening
   Dead bit of tissue / bone                                The sinus opening has pouting granulation tissue
   Persistent specific infection: tuberculosis,             Pain, if the track is blocked
     actinomycosis                                            There may be horse-shoe fistulae with two external
   Presence of tumour                                          openings and a single internal opening in the midline
   Communication with internal viscus                       Per rectal examination:
   Discharge of irritant material                               To identify the internal opening and direction of
   Obstructive distal lesion                                        the track (the track is felt as an indurated cord)
Aetiology of fistula in ano                                       (Anal gland ducts open normally at the level of
                                                                      dentate line and hence, the internal opening will
   Persistence of sepsis from infected anal-gland                   be usually near the dentate line)
     (common cause)                                               To evaluate any rectal disease – carcinoma,
   Improper drainage of abscess, e.g., following                    Crohn’s disease, ulcerative colitis
     folliculitis                                            Goodsall’s rule
   Continuous sepsis, e.g., tuberculosis, actinomycosis,   The site of the internal opening and direction of the track
     chronic fissure in ano, Crohn’s disease, ulcerative     can be predicted by this rule.
     proctocolitis, LGV                                       Fistulous openings anterior to a line drawn across the
   Associated disease of anorectum, e.g., Colloid              middle of anal orifice will have internal opening
     carcinoma of rectum                                         corresponding to external opening and track will be
Pathology                                                        straight
                                                              Those with external openings posterior to the line will
Classification                                                   have curved tracks and the internal opening is in
                                                                 midline posteriorly
Standard classification
                                                             Exceptions
   1) Subcutaneous
   2) Submucous                                               Anterior openings situated 4 cms away from anal


                                                                                      Yogi Ram’s lectures on Surgery
22 The rectum and the anus

     orifice will have curved tracts and opens posteriorly in    secondary track
     the midline
                                                                 Cause
Investigations                                                    This is usually due to probing of a low level fistula
                                                                    with accidental perforation of the rectum
To map the track in high level fistula
                                                                 Treatment
 M.R.I scan
 Endoluminal ultrasonography                                      Fistulectomy of the low level track and healing of the
                                                                      upper track follows usually
 Fistulogram
                                                                    If it fails to heal, or if the opening into the rectum is
To identify primary disease in the rectum                             present, a colostomy may be needed
   Proctoscopy
                                                                 2) Trans-sphincteric fistula with opening near
   Sigmoidoscopy
   Barium enema
                                                                 anorectal ring
   Colonoscopy                                                    A seton (i.e. a stout ligature of silk, nylon, or linen) is
   Chest X-ray for pulmonary tuberculosis.                          inserted through the track and left for 6 – 8 weeks
   HIV tests                                                      It acts as a drain and promotes fibrosis around the
   Fistulogram                                                      sphincter.
                                                                    Then, the sphincter can be cut as it is fixed by
Management                                                            surrounding fibrosis
   Depends upon the type of fistula and cause of fistula.      3) Intersphincteric fistula with an opening into
   Primary fistula in ano needs fistulectomy and               the rectum above the anorectal ring
     secondary needs correction of the underlying disease           It is easy to treat if recognised
     (e.g., tuberculosis, Crohn’s, carcinoma)                       The internal sphincter is divided and, whole track is
Fistulectomy/fistulotomy                                              laid open without fear of incontinence.
Principles of surgery                                            4) Supralevator fistula secondary to local
   Laying open of the track and all its branches and           disease
     allowing them to heal by secondary intention without        It occurs due to
     injuring the sphincters                                      Tuberculosis,
   Internal sphincter and part of the external sphincter        Crohn's disease,
     can be cut, but never the anorectal bundle                   Ulcerative colitis,
   Biopsy of the track is done to evaluate the cause            Carcinoma, or
   In low level fistula, laying open of the track does not      Due to a foreign body perforating the rectal ampulla
     injure anorectal ring and much of the external                   from above
     sphincter                                                   Treatment is that of the cause.
   In high level fistula, laying open of the track above the
     level of anorectal ring causes the incontinence and            A traumatic fistula usually needs colostomy.
     hence, procedure is modified                                   Fistulectomy is not done as it causes incontinence
Management of low level fistula                                  5) Supra sphincteric fistula.
   The fistulous track is laid open after passing a probe         Treatment of this type is very difficult and is done by
     through the external opening of the fistula by cutting           an indwelling seton
     the skin, subcutaneous tissues and the sphincter            Special clinical types of fistulae in ano
     muscle fibres
   The edges of the wound are cut to make the wound
                                                                 1) Fistula connected with an anal fissure.
     saucer shaped                                                  Pain (due to the fissure) is a leading symptom.
   The track is removed and sent for biopsy                       The fistula is very near the anal orifice, usually
   The branches of the track are identified and are dealt           posterior, and the external opening is often hidden by
     with similarly                                                   the sentinel pile.
   The wound is dressed and allowed to heal by                 2) Fistula associated with Tuberculosis and
     secondary intention                                         Crohn's disease
Management of high level fistula                                    Lack of induration around a fistula
It depends upon the type.                                           The external opening is ragged and flush with the
1) Trans-sphincteric fistula with perforating                         surface with undermined edges

Yogi Ram’s lectures on Surgery
                                                                                      The rectum and the anus 23

 The surrounding skin is discoloured                                  malnutrition
 The discharge is watery                                       In adults
 The external openings are multiple                               Third-degree haemorrhoids
Investigations                                                      After fistulectomy, where a large portion of
                                                                        muscle has been divided. (The prolapse is
 Biopsy from the track                                                localised to the damaged quadrant)
Treatment                                                           In females: perineal tear due to parturition
   Tuberculosis fistula responds to anti tuberculous              In males: straining from urethral obstruction
     treatment                                                      In old age: atony of the sphincters
3) Fistulae with many external openings                       Incidence
Causes
                                                                 Age:
   Tuberculous proctitis
                                                                    Extremes of life, between 1 and 3 years of age,
   Crohn's disease                                                  and in old people.
   Colloid carcinoma rectum
   Bilharziasis and                                         Treatment of partial prolapse
   LGV with a rectal stricture
                                                              In infants and young children
4) Carcinoma arising within perianal fistulae
                                                                 1) Digital reposition and in cases of malnutrition,
   Colloid carcinoma may complicate fistulae in ano and          dietetic adjustments are necessary
     a colloid carcinoma of the rectum is liable to be           2) Submucous injection
     complicated by perianal fistulae.
                                                                    Indication: failure of digital reposition
5) Hydradenitis suppurativa                                         Procedure: submucosal injections of 5 % phenol
   This is a chronic infection of apocrine glands around              in almond oil
     the anal margin, giving rise to numerous sinuses.                   Due to aseptic inflammation, the mucous
   The infection is confined to subcutaneous tissues only                  membrane becomes tethered to the muscle
   Treatment is by excision and skin grafting                              coat.
                                                                 3) Thiersch's operation.
PROLAPSE OF RECTUM                                                  Indications: failure of above procedures
                                                                    An encircling suture with silver wire or chromic
Types                                                                   catgut is inserted subcutaneously around the anal
                                                                        orifice tight enough to admit the index finger
   Partial
      Prolapse of only mucosa and submucosa of the          In adults
          rectum                                                 1) Submucous injections.
   Complete                                                       Phenol in almond oil in cases of early partial
      Prolapse of complete rectum                                    prolapse
Factors preventing prolapse                                      2) Excision of the prolapsed mucosa.
                                                                    Indications:
   Angulation of rectum
                                                                        Unilateral redundant mucosa
   Fat pads in ischiorectal fossae
                                                                    Procedure
   Tone of extrinsic and intrinsic anal sphincters, which
                                                                        Excision after inserting and tying Goodsall's
     provide support to the mucosa of the anal canal and
                                                                            ligature.
     also to the rectum
                                                                        Endoluminal stapling technique can now be
Aetiology                                                                   used

   In infants                                               Complete prolapse (procidentia)
      Straight course of the rectum due to the
                                                              It is less common. The protrusion consists of all layers of
          undeveloped sacral curve in the infants
                                                              the rectal wall and is a hernia-en-glissade of the rectum
      The reduced resting anal tone, causing diminished     through the levator ani. It is more than 4 centimetres and
          support to the mucosal lining of the anal canal.    usually 10 – 15 centimetres in length.
   In children                                              Anteriorly between its layers, a pouch of peritoneum with
      After an attack of diarrhoea                          small intestine may be present in a large prolapse.
      Severe whooping cough
      Diminution in the ischiorectal fat due to
                                                              Incidence
                                                                 Age

                                                                                      Yogi Ram’s lectures on Surgery
24 The rectum and the anus

        Uncommon in children.                                Ripstein’s operation
        In adults, it can occur at any age, but is more         After laparotomy and reduction of the prolapse, the
          common in the elderly.                                    rectosigmoid junction is hitched up by a Teflon sling
   Sex:                                                           to the front of the sacrum just below the sacral
      More common in women (usually associated with               promontory.
          prolapse of the uterus)
Differential diagnosis.                                        SOLITARY RECTAL ULCER
   Ileocaecal intussusception protruding from the anus.      Pathology
Treatment                                                      It is a non-specific ulcer on the anterior wall of the rectum.
Surgery
                                                               Causes
  Perineal approach
     Indications                                                Persistent trauma by sexual malpractices
         In elderly and very frail                              Chronic straining as a result of constipation
         Following injury or disease of the spinal cord            Due to a combination of internal intussusception
Perineal approach                                                       or anterior rectal wall prolapse
Two procedures have been used most commonly.                   Clinical features
 Delorme’s operation
 Thiersch’s operation                                           Bleeding per rectum
Delorme's operation                                               Mucus discharge
                                                                  Proctoscopy
   The rectal mucosa is removed circumferentially from             Non-specific ulcer on the anterior wall of rectum
     the prolapsed rectum over its length, apart from 0.5
     centimetre strips at its proximal end and at its tip.     Treatment
   The underlying muscle is then imbricated with a series
     of chromic catgut sutures, such that when these are          The condition, although benign, is difficult to treat.
     tied, the rectal muscle is concertined towards the anal      Symptomatic relief by preventing the internal prolapse
     canal.                                                         by an abdominal rectopexy
   The anal canal mucosa is then sutured                        In rare cases, rectal excision
     circumferentially to the rectal mucosa remaining at the
     tip of the prolapse.                                      PILONIDAL SINUS
   This manoeuvre has the effect of reducing the             Pilonidal means ` a nest of hair' (Latin: pilus = hair, nidus
     prolapse and creating a ring of muscle within the anal    = nest).
     canal, which narrows the orifice and prevents
     recurrence                                                Pathology
Thiersch’s operation
                                                               Sites
 Not advised in adults.
                                                                  Subcutaneously at the back of the sacrum, the usual
Abdominal approach
                                                                    site of its occurrence
The principle                                                     Umbilicus, axilla
   To replace and hold the rectum in its proper position        Interdigital clefts of barbers
     by an laparotomy                                          Aetiology
Types of operations
                                                               2 theories –
   Wells’ operation
                                                                  Congenital
   Ripstein’s operation
                                                                  Acquired: more acceptable cause
   Lahaut’s operation
Wells' operation                                               Pathogenesis
   After laparotomy, the rectum is mobilised, and the        Hairs broken off by friction against clothing collect in the
     prolapse is reduced. The rectum is fixed to the sacrum               cleft of the nates or a postanal dimple
     by inserting a sheet of polyvinyl alcohol sponge or                                      
     polypropylene mesh between them                              Due to shearing action of the buttocks, especially by
   The mesh produces marked fibrous tissue formation         vibration of a vehicle, intermittent negative pressure of the
   It is the operation of choice                                         area suck the loose hairs into the pit
   It is done by minimally invasive procedures also                                         

Yogi Ram’s lectures on Surgery
                                                                                          The rectum and the anus 25

        The hairs penetrate the skin or the open mouth of a         Fistulectomy and healing by secondary intention or
              sudoriferous gland and form a sinus.                    secondary skin grafting
     It was common among jeep riders in the Second World            Marsupialisation
               War, and is known as `jeep bottom'.
                                                                 Recurrent pilonidal sinus
Sequelae
      The sinus extends into the subcutaneous planes as an       Causes
          infected track with branching side channels.              Missed branches of the track at the operation
                                                                   New hairs again entering the skin or the scar
                      Subcutaneous abscess
                                                                HAEMORRHOIDS
        Bursts or incised usually to one side of midline
                                                                (Greek: haima = blood, rhoos = flowing)
                        Secondary sinus                          Synonym: piles (Latin: pila = a ball)

Clinical features                                                Definition
     Age and sex: males between 20 – 30 years.                 Haemorrhoids are masses of dilated veins occurring in
                                                                 relation to the anus.
     Chronic or recurring sinus in the midline about the
       level of the first piece of the coccyx.                   Types
     A tuft of hair projects from the mouth of the sinus
     The discharge is often bloodstained, and contains foul       External (external to the anal orifice; hence, covered
       sebum and sometimes hairs                                      by skin)
     The sinus track passes subcutaneously and does not           Internal (internal to the anal orifice; hence, covered by
       reach the bone, but ends blindly near the bone                 mucosa)
     Due to secondary infection, secondary openings may           Interno-external haemorrhoids
       develop from the sinus on either side of the midline
       with the primary opening seen in the mid line as a
                                                                 Pathology
       dimple or as a sinus                                      Pathological anatomy
     The track may be acutely inflamed and may present as
       an acute abscess                                          The haemorrhoids are congested and displaced anal
                                                                 cushions.
Differential diagnosis                                           Anal cushions
     Infected sebaceous cyst                                      These are highly vascularised thick submucosal
     Hydradenitis suppurativa                                       masses containing blood vessels, including
     Fistula in ano                                                 haemorrhoidal plexus, smooth muscle, and elastic and
     Post anal dermoid with sinus                                   connective tissue
                                                                    They are situated corresponding to the three terminal
Treatment                                                             branches of superior rectal artery (left lateral, right
                                                                      anterior and right posterior)
Of acute exacerbation with abscess                                  They aid in anal continence
     Rest                                                         Haemorrhoid is the dilatation of the internal venous
     Broad-spectrum antibiotic                                      plexus with an enlarged and displaced anal cushion
     Incision and drainage, if fails to resolve                Parts of haemorrhoid
     All hair and granulation tissue are removed from the
       abscess cavity                                            Internal haemorrhoids are frequently arranged in three
                                                                 groups at 3, 7, and 1l o'clock with the patient in the
     Later, the track is excised
                                                                 lithotomy position corresponding to the three terminal
Of chronic sinus                                                 branches of superior rectal artery. In between these three
Operation procedures                                             primary haemorrhoids, there may be smaller secondary
                                                                 haemorrhoids.
     Fistulotomy and marsupialisation: this procedure
                                                                 Each principal haemorrhoid can be divided in to three parts
       yields a good, hairless scar.
                                                                  The pedicle:
     Fistulectomy and primary skin-grafting:
                                                                       It is situated at the anorectal ring.
        Excision of all of the tracks meticulously. In cases
            of extensive sinus formation, primary cover may            It is covered with pale pink mucosa.
            be achieved by rotating a flap of skin and fat.            A branch of superior rectal artery is present
                                                                  The internal haemorrhoid:

                                                                                          Yogi Ram’s lectures on Surgery
26 The rectum and the anus

      It commences just below the anorectal ring.                Demonstrates their presence and degree.
      It is bright red or purple, and covered by mucous
        membrane.                                               Complications
     It is of variable size.                                     Profuse haemorrhage
 External associated haemorrhoid:                                   Most often it occurs in the early stages of the
     It lies between the dentate line and the anal                     second degree.
        margin.                                                    Strangulation:
     It is covered by skin                                          Prolapsed haemorrhoids  gripped by the
     This associated haemorrhoid is present only in                    external sphincter  strangulation,
        well-established cases                                     Gangrene  portal pyaemia
The majority of haemorrhoids are silent.
                                                                   Thrombosis
Aetiology                                                          Ulceration
The congested and displaced anal cushions occur due to –           Suppuration  pylephlebitis or portal pyaemia
 Gravity, straining, irregular bowel habits or hereditary        Fibrosis: following thrombosis,
    factors
They can also occur secondary to –
                                                                Differential diagnosis
 Carcinoma of the rectum: by compressing or causing              Prolapse of the rectum
    thrombosis of the superior rectal vein.                        Fissure in ano
 Pregnancy: due to compression of the superior rectal            Carcinoma rectum
    veins by the pregnant uterus and the relaxing effect of
    progesterone on the walls of the veins, plus an             Treatment
    increased pelvic circulating volume.
 Straining: stricture urethra, BPH, chronic constipation      Symptomatic treatment
 Portal hypertension: (rarely it is a cause)                  Indications
Clinical features                                                  When the haemorrhoids are secondary to other disease
                                                                Procedure
                                                                   Stool softeners and suppositories.
           Pathology                Clinical feature               Patients are advised not to strain during defecation.
      Congestion of anal        Bright red painless
                                                                Non-operative treatment
     cushions                    bleeding 
                                  Anaemia                     Injection treatment
      Sliding of anal           Prolapse                    Indications
     cushions                     Mucus discharge,             Bleeding I0 and early II0 haemorrhoids
                                 pain
                                                                Technique.
Depending upon the degree of prolapse, haemorrhoids are         3 to 5 ml of 5 % phenol in almond oil is injected into the
classified into –                                               submucosa at or just above the anorectal ring for each
 I degree: bleed but do not prolapse outside the anal         haemorrhoid.
     canal                                                      Cryosurgery
 II degree: prolapse on defecation but return                 Procedure
     spontaneously or manually.
                                                                The application of extreme cold (– 196°C) causes
 III degree: permanently prolapsed
                                                                coagulation necrosis of the piles, which subsequently
Examination                                                     separate and drop off.
Inspection                                                       Complications
                                                                     Troublesome mucus discharge and pain, and
    On inspection of the anal area, only prolapsed and                 hence, not used
      external haemorrhoids are seen out side the anal canal.
      The internal haemorrhoids are not seen.                   Photocoagulation
Per rectal examination                                          Application of infrared coagulation
                                                                 Indications: I0 haemorrhoids
    Internal haemorrhoids cannot be felt unless they are
      thrombosed.                                               Banding treatment (Barron)
Proctoscopy                                                     Indications

Yogi Ram’s lectures on Surgery
                                                                                        The rectum and the anus 27

 Second-degree haemorrhoids                                   Post-haemorrhoidectomy complications
Technique                                                       Early complications
A tight elastic band is slipped on to the base of the pedicle      Pain
of each haemorrhoid with a special instrument. The bands
                                                                   Retention of urine
cause ischaemic necrosis of the piles, which slough off
                                                                   Reactionary haemorrhage
within a few days. Two haemorrhoids are banded at each
session and an interval of three weeks is allowed between             It is much more common than secondary
each treatment. The procedure is painless and can be                      haemorrhage and the haemorrhage may be
performed as an outpatient procedure.                                     concealed
 Complication: infection                                            Treatment:
                                                                           Morphine and rest
Operative procedure                                                        Arrested by diathermy or under-running
Indications                                                     Late complications
   III0 degree haemorrhoids,                                     Secondary haemorrhage
   Failure of non-operative treatment of II0 haemorrhoids           It is uncommon
   Interno-external haemorrhoids                                    It occurs about the 7th or 8th day after operation.
Haemorrhoidectomy                                                     It is usually controlled by morphine but, if the
Types                                                                    haemorrhage is severe, the bleeding vessel is
                                                                         under-run.
 Open (Milligan-Morgan operation)                                Anal fissure and submucous abscess.
 Closed technique.                                               Anal stricture
Open technique
The haemorrhoids are removed by ligation and excision.
                                                                External haemorrhoids
The raw area is exposed and dressed till the wound heals        The swellings situated outside the annual opening around
by secondary intention.                                         the anal orifice are called as external haemorrhoids.
Closed technique                                                Types
The mucosal defect after excision of haemorrhoids is
                                                                   Thrombosed external haemorrhoid
closed completely with a continuous suture.
                                                                   External haemorrhoid associated with internal
In both the techniques, adequate mucosal and skin bridges
                                                                     haemorrhoid
between each area of excision are left so as to avoid a
subsequent stenosis.                                               Sentinel pile
                                                                   Dilated anal veins
Endostapling technique (MIPH)
                                                                1) Thrombosed external haemorrhoid
Minimally invasive procedure for haemorrhoids
                                                                (perianal haematoma)
This is done with a specially designed stapling gun. A strip
of mucosa and submucosa just above the dentate line is          It is a small clot occurring in the peri-anal subcutaneous
removed along with the veins and disconnecting the              tissue, usually superficial to the corrugator cutis ani
arterial supply to the haemorrhoidal plexus. The gun            muscle.
simultaneously sutures the edges of cut mucosa and              Cause
submucosa of anal canal to rectal mucosa and submucosa             Back-pressure on an anal venule due to straining at
relieving the prolapse also.                                         stool, coughing or lifting a heavy weight
Treatment of complications of haemorrhoids                      Clinical features
Severe haemorrhage                                                 Sudden and painful perianal swelling following
   Check for bleeding diathesis or usage of                        defecation
     anticoagulants.                                               On examination: tense, tender swelling on the lateral
   Blood transfusion, ligation and excision of the piles           region of the anal margin.
Strangulation, thrombosis and gangrene                          Course
   Analgesics and bed rest with frequent, hot sitz baths       Bursts and the haematoma comes out
   After 3 days, standard ligation and excision of the         Resolution
     piles is done.                                              Suppuration
   Lord’s dilatation, which was practised earlier, is not      Fibrosis  cutaneous tag
     practised nowadays for fear of incontinence.               This condition has been called `a 5-day, painful, self-
                                                                curing lesion'

                                                                                         Yogi Ram’s lectures on Surgery
28 The rectum and the anus


Treatment                                                           Investigation: Frei's reaction
   Incision and evacuation of the clot                            Treatment
                                                                       In the early stages, antibiotics
2) External haemorrhoid associated with                                In advanced cases, excision of the rectum
internal haemorrhoids (interno-external                          Endometriosis of the rectovaginal septum.
haemorrhoids)                                                       Presents as severe pain during the first 2 days of
These have been discussed in the topic on haemorrhoids.               the menstrual flow
3) Dilatation of the veins of the anal verge                  Clinical features of stricture
These are bluish, cushion-like veins covered by skin
                                                                 Increasing difficulty in defecation
appearing around the anus on straining, in persons leading
                                                                 Subacute or acute intestinal obstruction.
sedentary life. These are harmless.
4) Sentinel pile                                              Prevention
It is associated with an anal fissure (this was discussed        The passage of an anal dilator during convalescence
under fissure in ano).                                             after haemorrhoidectomy
Differential diagnosis of external                               Efficient treatment of LGV in its early stages
haemorrhoids                                                  Treatment
   Anal warts
                                                                 Dilatation by bougies
STRICTURE RECTUM                                                 Surgery
                                                                    Anoplasty: for postoperative strictures.
Classification                                                      Colostomy: it is indicated in intestinal
                                                                       obstruction, and in advanced cases of stricture
   Non-malignant
                                                                       complicated by fistulae in ano.
      Congenital
                                                                    Rectal excision and coloanal anastomosis: when
      Spasmodic
                                                                       the strictures are at or just above the anorectal
      Organic                                                        junction, and are associated with a normal anal
   Malignant                                                         canal
      Carcinoma rectum and anal canal
                                                              TUMOURS OF THE RECTUM AND ANAL
Congenital stricture
                                                              CANAL
   It is due to incomplete obliteration of the proctodeal
                                                              The tumours of the rectum and anal canal present as polyps
     membrane or following correction of imperforate anus
                                                              and all the polyps of the rectum and anal canal are not
Spasmodic stricture                                           tumours

   It follows acute anal-fissure                            Polyps of large bowel
Organic stricture                                             The term ‘polyp’ is a clinical description of any elevated
                                                              tumour.
It is due to
                                                              Classification of polyps of the large intestine
 Postoperative stricture
       Following haemorrhoidectomy.
       Low coloanal anastomosis
 Irradiation stricture
 Senile anal stenosis
       Due to internal sphincter contraction and fibrosis
       The treatment is internal sphincterotomy or
          dilatation at frequent intervals.
 Lymphogranuloma inguinale.
       Most frequent cause of a tubular inflammatory
          stricture
       Common in women and in black races
       May be accompanied by elephantiasis of the labia
          majora.
Yogi Ram’s lectures on Surgery
                                                                                   The rectum and the anus 29


         Class                     Varieties               Treatment of polyps
                                                              Removal and biopsy.
                                                              Colonoscopy to rule out lesions in the colon
                                                           Benign tumours of special importance in
                                                           rectum and anal canal
     Inflammatory          •Inflammatory polyps
                                                           Juvenile polyp (Raspberry tumour of the
                                                           rectum)
     Metaplastic           •Metaplastic or                    Age: infants and children (occasionally in adults)
                           hyperplastic polyps
                                                           Clinical features
     Hamartomatous         •Peutz-Jegher’s polyp              Bright red glistening pedunculated polyp (`cherry
                           •Juvenile polyp                      tumour')
                                                              Bleeds or painful, if prolapses during defecation

     Neoplastic            •Adenoma: tubular,
                                                           Treatment
                           tubulovillous, villous          It has no tendency to malignant change but needs treatment
                           •Adenocarcinoma                 if causing symptoms. It is excised with a snare or after
                                                           transfixation.
                           •Carcinoid tumour
                                                           Villous adenoma
Neoplastic Polyps                                          Pathology
Classification                                             It has a characteristic frond-like appearance. Sometimes, it
                                                           is very large occupying the entire rectum with a tendency
   Benign
                                                           to malignancy.
      Epithelial
          Adenomas                                       Clinical features
              Familial adenomatous polyposis (polyps        Profuse mucous discharge  hypokalaemia
                 more than 100)
                                                           Treatment
              Non-familial adenoma
                  Solitary                                  Submucous dissection per anum, or by sleeve
                  Multiple (polyps less than 100)             resection from above.
      Mesenchymal                                           Rectal excision when malignant change has occurred.
          Lipoma                                            Transanal endoscopic microsurgery (TEM): it is an
          Haemangioma                                         endoscopic endoanal approach for the local removal of
                                                                villous adenomas
          Stromal tumours
          Angiodysplasias, arterio-venous                Familial adenomatous polyposis
             malformations                                 Discussed in the chapter on Diseases of intestines
   Malignant
      Carcinoma                                          Differential diagnosis of polyps
      Carcinoid
                                                              Bilharzia
      Leiomyosarcoma
                                                              Benign lymphoma
      Lymphoma
                                                              Endometrioma.
      Melanoma
                                                              Haemangioma and
Benign tumours                                                Leiomyoma

Pathology                                                  CARCINOMA OF THE RECTUM
   The rectum, along with the sigmoid colon, is the      Incidence
     commonest site of polyps (and cancers)
   All neoplastic polyps are premalignant                In men, it is the second most common carcinoma in the
                                                           Western countries.
Suspicious malignancy in polyps
   If the polyp is more than 1 centimetre in diameter,   Pathology
   Sessile rather than a pedunculated shape.

                                                                                    Yogi Ram’s lectures on Surgery
30 The rectum and the anus

Premalignant conditions                                                lymphatics accompanying the middle rectal vein
                                                                       into internal iliac, in addition to the upward
   Adenoma (the adenoma-carcinoma sequence)
                                                                       spread
   Papilloma
                                                                     Downward spread is exceptional
Macroscopic types of carcinoma of the rectum                     Within 1 – 2 centimetres of anal orifice:
   Cauliflower /papilliferous                                      Along the subcutaneous lymphatics to the
   Ulcer                                                             inguinal nodes in addition to the upward spread
   Tubular                                                    N staging
   Annular (commonly seen at rectosigmoid)                       N1: pericolic and para colic lymph nodes
Microscopic appearance                                             N2: intermediate along the superior rectal vessels
It is an adenocarcinoma. Sometimes, mucoid or colloid              N3: pre and para aortic nodes at the origin of the
carcinoma can also develop in the rectum.                            inferior mesenteric artery

Colloid (mucoid) carcinoma                                      Blood spread
Incidence: 12 %                                                 It occurs late to liver, lungs, adrenals, and brain
 Types:                                                       Peritoneal dissemination
       Primary and                                            This may follow penetration of the peritoneal coat by a
       Secondary                                              high-lying rectal carcinoma leading to malignant ascites,
Primary mucoid carcinoma                                        and rectal shelf of Blumer.
It is a rapidly growing bulky growth, which metastasises        Stages of progression - Duke’s classification
very early and it carries a very bad prognosis. The mucus            A. The growth is limited to the rectal wall (15
lies within the cells, displacing the nucleus to the                    percent). Prognosis is excellent.
periphery, like the seal of a signet ring.                           B. The growth extended to the extra-rectal tissues
Secondary mucoid carcinoma                                              with no metastasis to the regional lymph nodes
It is more frequent. It is due to mucoid degeneration of an             (35 percent). Prognosis reasonable
adenocarcinoma. Histologically the glandular arrangement             C. The growth with secondary deposits in the
is preserved and mucus fills the acini. This type is of                 regional lymph nodes (50 percent).
average malignancy.                                                         .    C1: local pararectal lymph nodes alone
                                                                                 are involved
Spread                                                                      .    C2: nodes accompanying the superior
Local spread                                                                     rectal vessels are involved. Prognosis is
It occurs circumferentially rather than in a longitudinal                        bad.
direction. Usually 6 months is required for involvement of           D. (Not described by Dukes) distant metastases,
a quarter of the circumference, and 18 months to 2 years                usually hepatic.
for complete encirclement. Longitudinally, it infiltrates the   Stages of progression - TNM classification
muscular coat, mesorectum and para rectal structures –          Same as colon
 Anteriorly: the prostate, seminal vesicles or the
     bladder in the male and the vagina or the uterus in        Histological grading
     females.                                                      Well-differentiated
 Laterally: ureters                                              Moderately differentiated
 Posteriorly: sacrum and the sacral plexus.                      Anaplastic
 Downward spread for more than a few mms is rare
     except in anaplastic tumours.                              Clinical features
Lymphatic spread                                                 Age: usually above 55 years.
The lymphatics of the rectum pass in the mesorectum             Often the early symptoms are so slight that the patient does
(condensed para rectal tissue through which vessels enter       not seek advice for 6 months or more. The presenting
the rectum). The spread depends upon the site of the            symptoms are –
growth in the rectum.                                            Bleeding: this is the earliest symptom and is slight in
 Above the peritoneal reflection:                                  amount, and occurs at the end of defecation. The
      It occurs exclusively in an upward direction                 bleeding in every respect simulates that of internal
 In the field of the middle rectal artery, i.e. between 4          haemorrhoids (haemorrhoids and carcinoma may
     and 8 centimetres from the anus:                                coexist sometimes).
      Primary lateral spread occurs along the                  Sense of incomplete defecation: the patient may empty
                                                                     the rectum several times a day (spurious diarrhoea),
Yogi Ram’s lectures on Surgery
                                                                                         The rectum and the anus 31

    often with the passage of bloodstained mucus (`bloody       Preoperative assessment
    slime').
                                                                   Evaluation of the TNM stage
 Alteration in the bowel habit: this is the next most
                                                                   Fitness of the patient for operation
    frequent symptom.
 Pain:                                                        Treatment
     Pain is a late symptom due to infiltration of the           Operable tumours (T1-3, N0, M0)
        prostate or bladder                                           Radical surgery
     Pain in the back, or sciatica is due to invasion of         Inoperable tumours (T4, N1-3, M1)
        the sacral plexus                                             Palliative treatments
     Colicky pain is due to intestinal obstruction
 Weight loss                                                  Preoperative preparation
 Chronic or acute on chronic intestinal obstruction           Principles of radical surgery
Early symptoms of rectal cancer                                   Radical excision of the rectum, together with the
 Bleeding per rectum                                              mesorectum and associated lymph nodes
 Tenesmus                                                      As the lymphatic spread occurs proximally, the
 Early morning diarrhoea                                          proximal extent of resection is upto the sigmoid colon,
                                                                    and high proximal ligation of the inferior mesenteric
Abdominal examination
                                                                    lymphovascular pedicle is done to include N3 nodes
 Negative in early cases                                       As the distal spread is not present, rectum is excised at
 Signs of large intestinal obstruction in recto-sigmoid           2 centimetres below the margin of the growth
   growths                                                       The ano-rectal ring is three cms from anal verge.
 In advanced cases                                                Hence, growths above 5 – 6 centimetres from anal
    Ascites                                                       verge can be removed and continuity can be
    Hepatomegaly                                                  established
Rectal examination                                               The growths below 5 centimetres from anal verge and
                                                                    anaplastic growths need complete excision of rectum
   Approximately 90 per cent of the growths can be felt
                                                                    and anal canal
     on per rectal examination as a plateau, nodule, or as an
                                                                 In the presence of a solitary liver metastasis, a radical
     ulcer with everted margins or stricture
                                                                    excision can be done along with surgery of metastasis
   Sometimes, lymph nodes can be felt posteriorly or
                                                                    as the rectal cancer is slow growing
     postero-laterally above the tumour.
                                                                Complication: injury to autonomic nerves (pelvic plexus
   Bimanual examination is useful for high lesions            formed by fusion of hypogastric nerves (sympathetic) with
    In females, per vaginal examination is also of help       nervi erigenti) during posterior dissection causing bladder
Investigations                                                  and sexual dysfunction
                                                                Types of radical surgical treatment
   To diagnose the disease and evaluate the rest of colon
      Proctosigmoidoscopy and biopsy of the lesion to         1) Sphincter-saving operation (anterior
         grade the tumour                                       resection)
      Barium enema                                            Indications
      Colonoscopy
                                                                   Tumours of the upper two-thirds of the rectum.
   To evaluate the stage
                                                                   The introduction of the stapling gun has enabled even
      Endoluminal ultrasonography                                  the lower third tumours with the lower margin 2
      Ultra sound scan or CT scan for abdominal                    centimetres above the anorectal ring to be treated by a
         metastasis                                                  sphincter-saving procedure.
      X-ray chest for lung secondaries
                                                                2) Abdominoperineal excision of the rectum
Differential diagnosis                                          with a permanent colostomy
   Inflammatory stricture                                     Indications
   Amoebic granuloma                                             For tumours of the lower third of the rectum without
   Endometrioma                                                    lower margin clearance of 2 centimetres and for
   Carcinoid tumour                                                anaplastic tumours with the high risk of local
   The solitary rectal ulcer syndrome                              recurrence.

Treatment                                                       Anterior resection*
                                                                Methods


                                                                                         Yogi Ram’s lectures on Surgery
32 The rectum and the anus

 Open surgery                                                      operable
 Laparoscopy                                                  Radiotherapy
Excision of the rectum along with the growth as mentioned
in the principles of radical surgery is done and restoration    With modern techniques some adenocarcinomas now
of continuity is achieved by direct end-to-end anastomosis      respond to radiotherapy
(manually or by stapling) of colon to the rectal distal         Role of Radio-therapy
stump.                                                             1) Adjuvant therapy
(*The correct name of this operation is anterior                      Postoperatively to reduce recurrence
proctosigmoidectomy with colorectal anastomosis)                      Preoperative radiotherapy to downgrade and
Abdomino-perineal resection                                              downsize the tumour
Indications                                                        2) Palliative therapy
                                                                      For inoperable primary tumours or for local
    All tumours with lower margins within 2 cms from the               recurrence
      anorectal ring
                                                                      By Intracavity or interstitial radiation
 Anaplastic tumours
The pelvic colon is brought out as terminal pelvic              Chemotherapy and immunotherapy
colostomy after excision of the rectum and the anal canal.      Indications
Methods                                                          Adjuvant therapy
1) Synchronous abdomino perineal resection: two teams            Treatment of disseminated disease
perform the procedure simultaneously                            Drugs
2) Abdomino perineal resection: surgery is done by one
                                                                   5FU
team only. The abdominal part of the operation is done
first.                                                                Intra portal-venous administration of 5-FU during
3) Perineo abdominal operation: perineal operation is done               and immediately after the primary operation
first.                                                             Other drugs used as adjuvant therapy along with 5-
                                                                     FU:
More extensive radical operations                                     Systemic folinic acid (leucovorin)
Indications                                                           Levamisole (a nonspecific stimulator of the
   When the growth has spread to contiguous organs, the                immune process)
     radical operation is extended to remove these                    Various monoclonal antibodies to
     structures.                                                         carcinoembryonic antigen
      In the male, if the bladder is involved, cystectomy     Carcino embryonic antigen (CEA)
          along with resection of the rectum is done.
                                                                It is useful in monitoring the disease for recurrence and for
      In the female, hysterectomy + excision of the           evaluating the prognosis
          rectum is done, if uterus is infiltrated.
      If the bladder base is involved, pelvic                 Carcinoid tumour
          exenteration is done
                                                                Pathology
Pelvic exenteration (Brunschwig's operation)
                                                                It is a slow growing tumour and tumours greater than 2
The aim is to remove all of the pelvic organs, together with
                                                                centimetres are malignant. They metastasise late.
the internal iliac and the obturator groups of lymph nodes
along with urinary diversion.                                   Treatment
Palliative treatment                                               Local excision if less than 2 cms in size
                                                                   Resection of the rectum, if the growth is malignant
   Surgery
   Radiotherapy                                               CARCINOMA OF THE ANUS
   Chemotherapy
Surgery                                                         Types
   Trans-anal excision                                        The anal mucosa is entodermal in origin above the dentate
   Laser destruction                                          line and stratified skin below the dentate line. Hence,
   Hartmann's operation                                       tumours of the two types of mucosa occur from the anal
                                                                canal.
Carcinoma rectum presenting as acute                             Visceral cancers
intestinal obstruction                                                Lymphoma
   Pelvic colostomy or Hartman’s resection is done and              Mucoepidermoid carcinoma
     later, appropriate radical surgery is done, if tumour is
Yogi Ram’s lectures on Surgery
                                                                                        The rectum and the anus 33

   Skin cancers                                                 Inguinal nodal involvement:
      Squamous cell carcinoma                                      After excluding secondary infection by FNAC,
      Basal cell carcinoma                                            block dissection of one or both groins done
      Basiloid carcinoma                                     Treatment of squamous carcinoma of anal
      Melanoma
                                                               canal
Pathology                                                         For large infiltrating lesions
                                                                     Abdomino-perineal excision removing the growth
1) Squamous cell carcinoma                                               and the peri-anal area widely.
It is the commonest tumour.                                       If the inguinal lymph nodes are involved, a radical
Aetiology                                                           dissection of the groins is also done.
                                                                  Radiotherapy alone can be used for selected small
   Anal warts, in HIV cases                                       tumours by external beam, interstitial and intra-cavity
   Following radiation given for pruritus ani.                    techniques
   ? In the track of a long-standing fistula in ano and in
     Crohn’s disease of anal canal                             Chemo-radiotherapy
                                                               It is the preferred initial therapy for all anal canal tumours.
2) Basal cell carcinoma
                                                               A combination of 5-FU and mitomycin is given for 1
Same as elsewhere                                              week, followed by radiotherapy for 3 – 7 weeks. If there is
3) Basiloid carcinoma                                          residual tumour, an abdomino-perineal resection is
                                                               performed.
This is also known as cloacogenic carcinoma and is a form
of nonkeratinising squamous carcinoma. It is highly            Palliative therapy
malignant. It is not sensitive to radiation.                      In the frail patient with an advanced lesion,
4) Melanoma                                                         defunctioning colostomy is done.
It presents as a bluish-black soft mass, which is confused     BLEEDING PER RECTUM – CAUSES AND
with a thrombotic pile. Early spread by lymphatics and
blood occur. It is radio-resistant and has a very poor         INVESTIGATIONS
prognosis.
                                                               Causes
5) Mucoepidermoid carcinoma
                                                               Bleeding from the rectum can be as melaena or as frank
The tumour arises near the squamocolumnar cell junction,       bleeding. The various causes of bleeding due to lesions in
is of average malignancy, and is radiosensitive.               the stomach, and intestines were already discussed in the
6) Lymphoma                                                    appropriate chapters.
This may rarely affect the anal region with widespread         Causes of ano-rectal lesions
lymphomatous condition.
                                                                  Bleeding disorders
Clinical features of anal cancer                                     Purpura
                                                                     Haemophilia
Incidence: 2% of colorectal cancers                               Traumatic
Age: 50 – 60 years.                                               Inflammatory
Clinical presentation                                                Shigella or amoebic infection
   Rectal bleeding                                                 Ulcerative proctocolitis
   Mucus discharge                                                 Tuberculosis
   Tenesmus                                                        Schistosomiasis
   Sensation of a lump in the anus                                 Syphilis
   A change in bowel habit                                         LGV
   Mass in the inguinal region due to metastatic lymph             Solitary rectal ulcer syndrome
     nodes                                                           Fissure in ano
                                                                  Haemorrhoids
Treatment of squamous carcinoma of                                Tumours
anal canal                                                           Benign polyps: juvenile or hamartomatous polyp
                                                                         (commonly)
Tumours of the anal verge                                            Carcinoma
   Wide local excision with a margin of at least 2.5            Angiodysplasias
     centimetres

                                                                                         Yogi Ram’s lectures on Surgery
34 The rectum and the anus




History taking for a case of bleeding                         Presence of pain
/anus                                                            Painless: upper GI and piles
                                                                 Painful: fissure, prolapsed piles, inflammatory
   Age of the patient                                             conditions
      Children: polyp, prolapse, intussusception            Associated with mass per anus
      Adults: haemorrhoids, fissure                            Prolapse, prolapse of piles or polyp,
      Aged: carcinoma                                             intussusception
   H/O ingestion of anti-coagulants (e.g., vascular
     disease)                                              Steps of evaluation of torrential / slow /
   Relation with defecation                              chronic G.I blood loss
      Bleeding during defecation: from with in rectum
                                                              Intra oral examination
         or anus
                                                              Gums, palate, fauces, throat
      Bleeding apart from defecation: prolapsed piles,
                                                              Per rectal examination and proctoscopy
         rectal prolapse, fistula in ano
                                                              Upper GI Endoscopy
   Colour of blood per rectum
                                                              Colonoscopy
      Melaena: from upper gastro-intestinal tract and
         jejunum                                              Barium meal follow-through or enteroclysis or CT
                                                                enteroclysis in chronic slow bleeding
      Maroon: ileum
                                                              Selective mesenteric angiography or CT angiography
      Dark clots: right colon
                                                              99m Tc Pertechnate scan or bleeding scan with 99m
      Dark blood: sigmoid
                                                                Tc labelled R.B.C
      Frank blood: anorectum
                                                              Enteroscopy or intraoperative enteroscopy.
   Mixed with mucus or not
      Mucus mixed: dysentery, intussusception,
      Mixed with offensive discharge: carcinoma,



Yogi Ram’s lectures on Surgery
                                                                                                    The vermiform appendix 35



Chapter 4

               THE VERMIFORM APPENDIX
ANATOMY                                                                    Rare
                                                                            Agenesis
Appendix = annexum (a part attached to main structure)                      Duplication
It is vestigial diverticulum of large bowel. The three
longitudinal coats, i.e., taenia coli of colon fuse to form                INFLAMMATORY DISORDERS – ACUTE
single sheet of longitudinal coat of appendix. It is situated              APPENDICITIS
in the right iliac fossa arising from the base of caecum. It
has a mesentery transmitting appendicular artery, a branch                 Fitz coined the term acute appendicitis and advised early
of ileocolic artery. Its position is variable, but its base is             operation. It was called as perityphlitis before Fitz.
constant at Mc Burney’s point. It may be on the left side of
abdomen in situs inversus and non-rotation of the gut.                     Aetiology
Mc Burney’s point                                                          The probable causes are –
The surface anatomy of the appendix is variable, because                    Diet
of its variable positions. But, its base is constant at this                    More prevalent in non - vegetarians (? cellulose
point, which is situated on the spino-umbilical line (a line                       content in the vegetarian food provides
joining anterior superior iliac spine with umbilicus) at the                       protection)
junction of its lateral one-third to medial two-thirds.                     Familial predisposition
                                                                            Obstruction to appendix
Position of the appendix in relation to caecum                              Intra luminal causes
Its position is variable –                                                      Faecolith
 Retrocaecal: 74%                                                             Foreign bodies
 Para caecal: 2%                                                              Worms (pinworms)
 Sub caecal: 1.5%                                                         Intra mural causes
 Pre ileal: 1%                                                                Stricture
 Post ileal: 0.5%                                                             Neoplastic: carcinoids, carcinoma
 Pelvic: 21%                                                              Extramural causes
Histology                                                                       Kinks
It is same as that of colon. In addition, it contains                      Pathology
Kulchitsky (argentaffin cells) cells.
                                                                           Progress of appendicitis
CONGENITAL ANOMALIES
                                                                           The inflammation progresses as follows –

                                                        Appendicular inflammation




                                1) Local spread              2) Localisation               3) Resolution


                                Local peritonitis             Mass / abscess            Fibrosis of appendix
                                      and
                                 later general
                                  peritonitis


Types of inflammation                                                      In catarrhal inflammation, it can resolve or form an abscess
                                                                           or mass and rarely, general peritonitis. But, in obstructive
   Catarrhal (non obstructive)                                           appendicitis, there will be usually spreading peritonitis
   Obstructive

                                                                                                    Yogi Ram’s lectures on Surgery
36 The vermiform appendix

Catarrhal appendicitis                                          Obstructive appendicitis
It can progress as –                                            Pathology
 Local spreading inflammation                                          Obstruction to the lumen of the appendix
 Localised infection                                                                        
 Resolution                                                        Distension of the appendicular lumen distal to the
1) Local spread                                                                         obstruction
Inflammation and oedema of mucosa spreading to muscle                                         
                         coat                                                    Raised intramural tension
                                                                                             
          Inflammation spreads to serous coat                               Gangrene of the appendicular wall
                                                                                             
                   Local peritonitis                                              Perforation of appendix
                                                                                             
                  General peritonitis                                             Peritonitis (generalised)
                                                                                 Rarely, a mass may from.
Spread of infection
Methods of spread                                               Sequelae of acute appendicitis
 A) Gradual transmural spread                                 Catarrhal appendicitis
 B) Intramural oedema causing occlusion of terminal              Resolution
   part of appendicular artery  gangrene and                         Fibrosis at the tip
   perforation of the tip of the appendix  spreading                 Mucocele
   peritonitis                                                     Appendicular mass and later, appendicular abscess
Factors for spreading of infection                                 Gangrene and perforation
   Abuse of purgatives (promotes peristalsis)                    General peritonitis
   Perforation of appendix                                    Obstructive appendicitis
   Extremes of age                                               Gangrene
   Pelvic appendix                                               Peritonitis
   Previous abdominal operations which limit the                 Rarely, resolution
     mobility of greater omentum and
   Decreased host resistance                                  Clinical Features
      Diabetes mellitus, HIV, immuno-suppression
         therapy                                                Incidence
2) Localisation of infection                                       Acute appendicitis is the commonest cause of acute
                                                                     surgical abdomen in young adults.
   When host resistance is good, the fibrinous exudate             Age:
     collects on the serosal surface of the appendix
                                                                      Rare in infants and commonly seen in young
                                                                         adults.
Adhesions occur between adjacent bowel loops, appendix
                                                                      Relatively uncommon after middle age.
      and greater omentum (infection is localised)
                                                                   Sex:
                            
                                                                      More common in males (M: F = 3:2)
                   Appendicular mass
Pus may collect in between the coils of the intestines in the   Clinical presentation
                          mass                                  It varies according to
                                                                Nature of inflammation (catarrhal /obstructive
                  Appendicular abscess                               appendicitis),
3) Resolution                                                    Position of appendix
If the host resistance is good and the inflammation is mild,     Age of the patient and
the inflammation may resolve and the appendix can                Associated conditions like pregnancy
become one of the following –                                   Clinical presentation of catarrhal appendicitis
 Becomes normal (complete resolution with out
     sequelae)
                                                                General features
 Its tip may become fibrosed                                  They are like that of any acute inflammation –
 It may develop into mucocele                                  Low grade fever
                                                                 Malaise
Yogi Ram’s lectures on Surgery
                                                                                          The vermiform appendix 37


   Tachycardia                                                    Initially presents as a colic in umbilical region (D.D:
Local features                                                        intestinal obstruction)
                                                                    Other features are similar to catarrhal appendicitis, but
Symptoms                                                              progresses more rapidly
 Shifting pain                                                    This condition can progress to general peritonitis with
 Nausea and vomiting                                                rapidity
Signs                                                            Atypical clinical presentation
    Localised tenderness in the right iliac fossa with            Pain of visceral or somatic may dominate without the
      maximum point of tenderness at Mc Burney’s point.               other element of pain
 Localised guarding in the right iliac fossa                         This occurs in retrocaecal and pelvic positions
Shifting pain                                                             and in senile patients.
Pain umbilical area shifting after few hours to right iliac      Clinical presentation according to position
fossa and this type of pain is called as shifting pain and it
is a characteristic feature of acute appendicitis.               Retrocaecal acute appendicitis
As the appendix is a midgut structure, pain is felt initially       Localised pain and guarding in right iliac fossa may be
in the umbilical region. After six to eight hours, the                absent
infection from the mucosa of the appendix spreads to                Fixed flexion deformity of hip and pain on extension
serosa and later to the local peritoneum in the right iliac           of hip
fossa, causing pain in the right iliac fossa.
                                                                 Pelvic acute appendicitis
Nausea and vomiting
                                                                    Strangury due to irritation of bladder
It is due to reflex pylorospasm.                                    Tenesmus due to irritation of rectum
Tenderness                                                          Tenderness
It is due to local peritonitis and swollen and turgid                  It may be absent in right iliac fossa, but may be
appendix. It is felt in right iliac fossa, but with maximum               present just above and to the right of the
point of tenderness at Mc Burney’s point.                                 symphysis pubis. It is elicited by per rectal
Rebound tenderness                                                        examination or by Cope’s test
                                                                       Cope’s test: when the hip is flexed and internally
It is due to rubbing of the surfaces of parietal peritoneum
                                                                          rotated, pain is felt in the hypogastrium.
and the inflamed appendix on sudden release of the
palpating hand in the right iliac fossa.                         Pre ileal or post ileal acute appendicitis
Cough test                                                          Diarrhoea due to irritation of lower ileum
A bout of cough causes pain in right iliac fossa due to          Variations in clinical presentation due to age
same reason.
                                                                 Infants and children
Guarding
                                                                    Usually, they present with crying
It is due to reflex spasm of overlying abdominal wall
                                                                    Diarrhoea is the presentation in this age group because
muscles.
                                                                      the appendix is higher up and irritates the bowel loops.
 In paracaecal, ileal and pelvic appendicitis, it is felt in
                                                                      (In adults, diarrhoea occurs only in pre ileal and post
      the right iliac fossa
                                                                      ileal appendicitis).
 In retrocaecal appendicitis, reflex spasm of psoas
                                                                    Pyrexia of less than 38.50C.
      muscle occurs producing pain on extension of the hip
                                                                    Early general peritonitis can occur due to ill-
      (psoas sign).
                                                                      developed greater omentum
 In pelvic appendicitis, the obturator internus muscle is
      spastic causing pain on internal rotation of the hip       Old people
      (Cope’s obturator test)                                       Muscles are lax and reflexes are dull, hence guarding
Progress of symptoms                                                  is minimal or absent, but tenderness is present.
The events in a patient with acute appendicitis usually             Appendix is prone for gangrene and early peritonitis
follow in this order –                                                due to atherosclerotic changes in the blood vessels of
 Pain umbilical area shifting to right iliac fossa in 6 – 8         the appendix
      hours time                                                    The compromised haemodynamic system may lead to
 Anorexia, nausea, vomiting                                         high mortality.
 Pyrexia                                                       Clinical presentation according to the
Clinical features of obstructive appendicitis                    associated conditions

                                                                                          Yogi Ram’s lectures on Surgery
38 The vermiform appendix


Pregnancy                                                          Tenderness and guarding is present over the upper
                                                                     abdomen initially
   Classical obstetric teaching says that appendix is
     displaced upwards due to growing uterus and hence,            Guarding may be seen in the right iliac fossa due to
     pain, tenderness and guarding are felt in right lumbar          fluid passing along the right para colic gutter to the
     region and more laterally. But, usually the pain is felt        right iliac fossa
     in the right lower quadrant of the abdomen.                Acute cholecystitis
   Inflammatory exudate may irritate the uterus and may          Pain is felt in the right hypochondrium, with radiation
     cause miscarriage or pre-term labour (the risk is               to inferior angle of right scapula and sometimes to the
     greater with near the term and in perforated acute              root of the neck
     appendicitis)                                                 Murphy’s sign is positive
Obese                                                           Acute pancreatitis
   Difficult to elicit tenderness and guarding                   Pain radiates to back described as illimitable agony
Clinical features of acute appendicitis with                       Guarding may be absent (guarding is not in proportion
general peritonitis                                                  to severity of the pain)
                                                                   Associated with ileus
   General features
                                                                   Associated general features of shock may be present
      High grade pyrexia
      Profuse, frequent vomiting and contains bile and        Diseases of lower abdomen
         intestinal juices                                      Enterocolitis (to be differentiated from post
      Tachycardia of more than 120 / min
                                                                ileal appendicitis)
      Dehydration and toxaemia
   Local features                                                Presents with nausea, vomiting and diarrhoea
      Generalised tenderness with guarding                       Associated with colic
      Abdominal distension with absent bowel sounds              No well localised tenderness
                                                                   No guarding
Alvarado scoring for diagnosing acute                           Amoebic typhlitis
appendicitis
                                                                   No shifting pain
   Symptoms                                                      No guarding
      Shifting pain = 1                                          May be associated with dysentery
      Anorexia = 1                                            Intestinal obstruction
      Nausea and vomiting = 1
   Signs                                                         Colicky periumbilical pain (also occurs in obstructive
                                                                     appendicitis)
      Tenderness in right iliac fossa = 2
                                                                   No shifting pain
      Rebound tenderness = 1
                                                                   Distension, vomiting, and visible peristalsis (step-
      Pyrexia = 1
                                                                     ladder pattern) is seen
   Investigations
                                                                   Guarding, only when there is strangulation
      Leucocytosis = 2
      Shift to left (segmented neutrophils) = 1               Mesenteric lymphadenitis
    Total score more than 7 is highly indicative of acute        Usually occurs in children
     appendicitis                                                  Shifting tenderness: pain and tenderness in the right
                                                                     iliac fossa shifts to the umbilical region, if patient is
Differential diagnosis of acute                                      turned to left lateral position
appendicitis                                                       No guarding
Because of variable clinical presentations, acute               Enteric perforation
appendicitis has to be differentiated from all other acute
                                                                   Manifests during 2nd or 3rd week of enteric fever
abdominal conditions.
                                                                   Pain in the right lower quadrant of the abdomen
Upper abdomen diseases                                             Features of general peritonitis are seen predominantly
Perforated peptic ulcer                                              and from the beginning
                                                                   Patient is toxic
   Pain first starts in the epigastrium or right
     hypochondrium, which is well localised, severe, and        Meckel’s diverticulitis
     excruciating (in acute appendicitis, the pain is dull         Clinically, it cannot be differentiated from acute
     aching and diffuse.)                                            appendicitis
Yogi Ram’s lectures on Surgery
                                                                                       The vermiform appendix 39

Acute regional ileitis (Crohn’s disease) or                   Neurological
terminal ileitis due to yersinia infection                    Pre- herpetic neuralgia of T10 and T11
   Diarrhoea precedes pain (pain precedes everything in     dermatomes
     acute appendicitis)
                                                                 Shifting pain is absent
   Tenderness with out guarding
                                                                 Guarding is absent
   A tender lump may be palpable in the right iliac fossa
                                                                 Marked hyperaesthesia of affected dermatome is
Rectus sheath haematoma                                            present
   H/O strenuous physical exercise                          Acute radiculitis
   Pain and mass over the rectus abdominus muscle with      Acute radiculitis due to diseases of the vertebral column,
     out any gastro-intestinal symptoms                       e.g., tuberculosis, disc prolapse, tumours of the vertebra,
Diseases of the pelvis                                        lumbar spondylosis, osteoporosis
Salpingitis                                                   Metabolic causes
   Pain on both sides of the pubic tubercles                Porphyria crisis
   Pyrexia of more than 380 C                                  Abdominal and neurological symptoms with
   H/O mucopurulent vaginal discharge                            intermittent attacks of severe colicky pain in the lower
   Per vaginal examination: tenderness of cervix and             abdomen
     fornices                                                    High coloured urine turning to deep orange colour
Ectopic pregnancy                                                  when kept in sunlight
                                                                 Diabetic ketoacidosis
Tubal abortion or rupture may resemble acute appendicitis
in the early stages                                              Tabetic crisis
 No evidence of shifting pain                                  Henoch-Schonlein purpura
 H/O missed period                                          Differential diagnosis depending upon the age
 Tender cervix                                              In infants and children
 Features of haemoperitoneum (shoulder tip pain, local
     guarding) may be seen                                       Enterocolitis
                                                                 Acute mesenteric lymphadenitis
Twisted ovarian cyst                                             Meckel’s diverticulitis
   Pain in the umbilical region / loin                         Intussusception
   Per vaginal examination: tender mass is felt in the         Henoch-Schonlein purpura
     fornix                                                      Lobar pneumonia
Mittelschmerz (ruptured ovarian follicle)                     In adults
                  th     th
     Pain during 14 or 15 day of menstrual cycle in the          Perforated peptic ulcer
     lower abdomen                                               Ileal perforation
   Bleeding per vaginally                                      Ureteric colic
   Symptoms subside with in hours                              Intestinal obstruction
Diseases of retroperitoneum                                      Regional enteritis
                                                                 Acute pancreatitis
Ureteric colic                                                   Rectus sheath haematoma
   Pain from loin to groin                                     Torsion of right testis
   No guarding
   Tenderness may be present in the course of ureter
                                                              In adult females
   Dysuria may be present                                      Mittelschmerz
                                                                 Acute salpingitis
Right pyelonephritis                                             Ectopic pregnancy
   Fever with chills and rigor                                    Tubal abortion
   Dysuria                                                        Rupture
   Loin pain and tenderness                                    Torsion of ovarian cyst
Right testicular torsion                                         Acute pyelonephritis
   Pain in the scrotum referred to the right iliac fossa    In elderly
   Scrotal examination reveals a tender twisted cord and       Intestinal obstruction
     testis                                                      Mesenteric infarction

                                                                                       Yogi Ram’s lectures on Surgery
40 The vermiform appendix

   Diverticulitis                                               Differential diagnosis
   Aortic aneurysm
                                                                     Ileo caecal tuberculosis
Investigations                                                       Carcinoma caecum
                                                                     Amoeboma.
   Blood count
                                                                     Crohn’s disease.
      Polymorphonuclear leucocytosis more than 15000
                                                                     External iliac lymphadenitis
         / mm3
   Urine examination –                                          Investigations
      Microscopic examination to differentiate
         pyelonephritis, ureteric colic, porphyria                   Blood counts
      Pregnancy test in suspected cases of tubal                   Urine examination for microscopy
         pregnancy                                                   Stool examination for occult blood.
   Plain X- ray abdomen in erect posture to exclude                Radiological
     perforation of viscus                                              Ultra sound scan
   Ultra sound scan                                                   Barium meal after resolution of acute stage
      Inflamed appendix may be seen as non-                        Colonoscopy
         compressible, aperistaltic tubular structure with a
         dilated lumen and thick wall in right iliac fossa        Management
      Useful in children                                        Aims
      Not very reliable in adults
                                                                   To help the body to contain the inflammation
      More useful to exclude pelvic disease, e.g., tubal
                                                                   To identify when inflammation spreads to the
         pregnancy, ovarian cyst
                                                                     peritoneal cavity and to deal with it by surgery
   Laparoscopy
                                                                   To manage the infected appendix after resolution of
      To differentiate diverticulitis and pelvic
                                                                     the mass
         conditions
                                                                  Method
Treatment                                                            By conservative management (Ochsner-Sherren
The treatment of acute appendicitis is appendicectomy.                 regimen), as surgery entails the risk of damaging the
The surgery should be done with out any unnecessary                    inflamed and friable bowel in the vicinity and
delay.                                                                 spreading the infection to the general peritoneal
                                                                       cavity.
Contra indications for emergency surgery
                                                                  Ochsner - Sherren regimen
   Appendicular mass
                                                                     1) Rest to the bowel
APPENDICULAR MASS                                                       Nasogastric aspiration and nothing by mouth till
                                                                           peristalsis resumes and the pain subsides, usually
Pathology                                                                  for one to two days
                                                                        I.V. fluids for 48 hours and liquid diet there after
It is a mass of inflamed appendix and oedematous caecal
                                                                        Enemata / purgatives are avoided
wall with adherent loops of oedematous terminal ileum
wrapped with greater omentum.                                        2) Antibiotics
It occurs 48 hours after the onset of acute appendicitis. It is         Broad spectrum antibiotics with metronidazole
due to the host resistance to contain the infection locally.         3) Analgesics and sedatives are given for 2 to 3 days
The inflamed appendix gets circumscribed by fourth or                4) Monitoring for signs of spreading infection
fifth day and forms a mass. The mass increases in size up               Pyrexia and tachycardia: a rising pulse rate is the
to tenth day and subsides usually by third week. The mass                  sensitive and the earliest sign of spreading
increases in size after ten days, if an abscess has formed.                peritonitis
                                                                        Vomiting
Clinical features                                                       Pain becomes severe and diffuse
   Classical features of acute appendicitis followed by a             Persistence or spreading of guarding / tenderness
     painful lump in the right iliac fossa                              Increase in the size of the mass (indicates abscess
   Some times the mass may not be palpable due to                        or diagnosis is incorrect)
     overlying guarding of the abdominal wall                        5) Dealing with appendix
   General features of inflammation, namely pyrexia,                  Once the lump resolves, appendicectomy is done
     malaise and tachycardia are present                                   after an interval of six weeks
                                                                        This procedure is called interval appendicectomy
Yogi Ram’s lectures on Surgery
                                                                                          The vermiform appendix 41

Contra indications for Ochsner-Sherren’s                           Carcinoid tumour
regime                                                             Carcinoma
   In children:                                               Carcinoid tumour (argentaffinoma)
      As the greater omentum is not well developed, the
          chances of spreading inflammation and general         It is the commonest neoplasm of the appendix. It arises
          peritonitis is high                                   from Kulchitsky cells of crypts of Lieberkuhn.
   In old people                                              Histology
      As the incidence of gangrene and perforation is         The cells are stained by immuno-histochemical stain for
          high due to atherosclerotic changes in the vessels    Chromogranin B.
   Immuno compromised patients
   When the mass has not formed                               Clinical features
   When the diagnosis is in doubt                                Mild, recurrent pain in the right iliac fossa.
Indications for surgery during the course of                    Investigations
conservative treatment                                             Laparoscopy
   Signs of spreading infection                               Treatment
   If the lump fails to resolve, ileocaecal tuberculosis,        Appendicectomy, if the tumour is less than two cms in
     carcinoma caecum or Crohn’s disease should be                   size.
     suspected.
                                                                   Right hemicolectomy, if the tumour is larger than 2
APPENDICULAR ABSCESS                                                 cms in size or associated with secondaries in liver,
                                                                     carcinoid syndrome or if the appendicular tumour is
Pathology                                                            adherent to surrounding structures.

It is formation of pus in the appendicular mass.                Carcinoma of appendix
Clinical features                                               It is extremely rare.

The mass and general signs of inflammation continue to          Treatment
increase even after 10th day
                                                                   Right hemicolectomy.
Investigations                                                     If the diagnosis is made after appendicectomy, a
                                                                     revision operation is done for right hemicolectomy.
   1) Ultra sound / CT scan: To see for liquefaction.
                                                                MUCOCELE OF APPENDIX
Treatment
                                                                Pathology
   Once the abscess is well localised, it should be drained
     extra-peritoneal (see drainage of intra peritoneal         It is due to collection of mucoid material in the lumen of
     abscess).                                                  appendix causing it to distend enormously.
   If appendix is located, appendicectomy is done.
   If appendix not located, interval appendicectomy is        Causes
     done.                                                         Stricture
ACUTE APPENDICITIS COMPLICATING                                    Carcinoid
                                                                   Foreign body
CROHN’S DISEASE
   If the caecal wall is healthy at the base of appendix,
                                                                Complications
     appendicectomy can be performed.                              1) Rupture  pseudomyxoma peritonei. (The other
   If the caecal wall is inflamed, local resection of              causes of pseudomyxoma peritonei are colloid
     involved ileum and caecum is advised                            carcinoma of the rectum, and mucinous cystadenoma
                                                                     of the ovary)
TUMOURS OF THE APPENDIX                                            2) Infection  Empyema of appendix
Pathology                                                       Clinical features
They are rare                                                      Mild pain and tenderness in the right iliac fossa.
Types
                                                                Treatment

                                                                                          Yogi Ram’s lectures on Surgery
42 The vermiform appendix




   Appendicectomy.                                                  Empyema
                                                                   Reactionary haemorrhage from the appendicular
APPENDICECTOMY                                                       vessels
                                                                   Leakage from the stump of the appendix
Procedure of appendicectomy                                        Wound infection: the commonest complication
   Incision: one of the following is done.                       Residual abscess
      Grid-iron incision or muscle splitting incision               Paracaecal, pelvic, subphrenic
           It is made at right angles to spino-umbilical         Postoperative intestinal obstruction
               line at Mc Burney’s point                              Paralytic ileus
           The incision can also be made in the crease              Mechanical obstruction from adhesions
               line near the Mc Burney’s point                        Caecocolic intussusception (appendix stump acts
      Midline / right lower paramedian incision in                      as lead point)
          doubtful cases                                           Thromboembolism
   Skin and subcutaneous tissues are incised                     Parotitis
   External oblique aponeurosis incised in the line of its       Portal pyaemia and thrombosis
     fibres                                                        Ileocaecal actinomycosis
   Internal oblique and transversus abdominis muscles            Faecal fistula
     are split
                                                                Late postoperative
   Fascia transversalis and pre peritoneal fat incised
   Peritoneum incised                                            Ventral hernia
   Appendix is located by following the taenia coli of           Inguinal hernia due to injury to ileo-hypogastric nerve
     caecum to its posterior wall                                  Adhesions causing intestinal obstruction
   Mesoappendix is transfixed and cut, appendix is
     crushed at its base and ligated with chromic catgut
                                                                INVESTIGATION OF A CASE OF POST
   A purse string suture over the base of caecum around       OPERATIVE PYREXIA
     the appendicular stump inverts the stump                   A male aged 56 years underwent appendicectomy for acute
   Peritoneal exudate is mopped away and the wound is         appendicitis. He developed fever on 3rd postoperative day.
     closed in layers                                           How do you investigate?
Alterations in the procedure                                     Examine the wound and the abdominal wall for
                                                                    infection
   Lanz incision at Mc Burney’s point
                                                                 Examine for jaundice and tender hepatomegaly
   Rutherford Morison’s muscle cutting incision when
                                                                    (pylephlebitis)
     access to appendix is not sufficient to deliver the
     caecum                                                      Examine the loin for tenderness or swelling
                                                                    (pyelonephritis or retrocaecal collection)
   Retrograde appendicectomy when appendix is
     retrocaecal and closely applied to the posterior wall of    Check urine for pus cells
     caecum                                                      Examine left iliac fossa and per rectal examination
   Some surgeons do not invert the appendicular stump             (abscess in left iliac fossa or pelvic abscess)
   Laparoscopic appendicectomy                                 Examine the legs for tenderness and swelling
                                                                    (phlebothrombosis)
COMPLICATIONS OF                                                 Examine the drip site for thrombophlebitis
APPENDICECTOMY                                                   Exclude malaria
                                                                 Examine lungs for pneumonitis
Early postoperative                                              If no abnormality is detected, suspect
   Retention of urine                                             subdiaphragmatic abscess and ultra sound/CT scan is
                                                                    done
   Chest complications
      Bronchial pneumonia
      Atelectasis



Yogi Ram’s lectures on Surgery
                                                  The peritoneum, omentum, mesentery and retroperitoneal space 43


Chapter 5

          THE PERITONEUM, OMENTUM,
                MESENTERY AND
           RETROPERITONEAL SPACE
            THE PERITONEUM                                        Classification
                                                                     Acute
ANATOMY
                                                                     Chronic
The peritoneal cavity is the largest cavity in the body. It is          Tuberculosis
divided into greater and lesser sacs. The surface area of the           Non-specific
whole peritoneum is two m2 (equal to that of the skin)
The peritoneum is of two parts –                                  ACUTE PERITONITIS
 The visceral peritoneum (surrounding the viscera)
     Innervated by autonomic nerves
                                                                  Aetiology and pathology
 The parietal peritoneum (lining the inside of the              Infection by –
    abdominal wall)                                                Bacteria
     Innervated by somatic nerves                                    Gastrointestinal bacteria
Microscopic Anatomy                                                    Non-gastrointestinal bacteria
                                                                   Viral
It is lined by single layered flattened polyhedral cells          Gastrointestinal bacteria
(mesothelium), which have regenerative capacity. It
secretes and absorbs fluid. The fluid is pale yellow and           They are aerobic and anaerobic bacteria like
contains mainly lymphocytes. Normally, only few ml of                escherichia coli, aerobic and anaerobic streptococci,
fluid is found in the peritoneal cavity.                             and the bacteroides
                                                                   Less frequently Clostridium welchii, still less
FUNCTIONS OF THE PERITONEUM                                          frequently staphylococci or Klebsiella pneumonia
                                                                     (Friedlander’s bacillus) are the causative organisms
   Pain perception (parietal peritoneum)                         These Gram negative bacteria produce endotoxins
   Visceral lubrication
                                                                  Source of infection
   Fluid and particulate absorption
   Inflammatory and immune responses                               By transmural migration due to
   Fibrinolytic activity of its secretions                            Infection, ischaemia or obstruction of the bowel
                                                                           or
PERITONITIS                                                             Through perforated bowel wall

Causes                                                            Non-gastrointestinal bacteria
                                                                   Chlamydia, gonococcus, beta-haemolytic
   Microbial infection                                             streptococcus, pneumococcus and mycobacterium
      E.g. appendicitis, tuberculosis                              tuberculosis
   Chemical injury                                              Source of infection
      E.g. bile peritonitis
                                                                     In young girls and women, via the Fallopian tubes
   Ischaemic injury
                                                                     Exogenous contamination
      E.g. strangulated bowel, vascular occlusion
                                                                        Trauma
   Direct trauma
                                                                        Via drains
      E.g. operation
                                                                     Haematogenous spread
   Allergic reaction
                                                                     In immuno-deficient patients, opportunistic peritoneal
      E.g. starch peritonitis
                                                                       infection, e.g. mycobacterium avis

                                                                                          Yogi Ram’s lectures on Surgery
44 The peritoneum, omentum, mesentery and retroperitoneal space


Pathology                                                       Clinical features
The infection may be localised or generalised.
                                                                Early features
Progress of infection                                              Systemic features of infection and shock
                                                                     (hypovolaemia and septicaemia)
                              Local
                              Local                                   Pyrexia and rapid pulse
                            Peritonitis
                            Peritonitis                               Vomiting
       Spreads to general
                                          Localisation with        Local features of infection
        peritoneal cavity
                             Resolution   abscess formation           Pain and tenderness
     from the site of sepsis                                          Rebound tenderness
                                                                      Guarding
                                                                      Associated sequelae like paralytic ileus
          • Copious fluid exudation  hypovolaemic shock
                                                                   In generalised peritonitis, these features manifest
        • Endotoxin absorption  septicaemia and toxaemia            diffusely
         • Associated reflex paralytic ileus  hypovolaemic
            shock and distension of abdomen  respiratory
                                                                Clinical features - Late
                            embarrassment                          Progressive distension of abdomen without bowel
                                                                     sounds
                                                                   Peripheral circulatory failure
Factors for localisation                                              Cold, clammy extremities, sunken eyes, dry
     Anatomical                                                        tongue, thready (irregular) pulse, and drawn and
        The greater sac of peritoneum is divided into                  anxious face with over-active ala of nose
           various compartments, which localises the                     (Hippocratic facies)
           infection to these compartments. The                    The patient finally lapses into unconsciousness.
           compartments are –
            (a) The subphrenic spaces                         Investigations
            (b) Supracolic and infracolic compartment            Blood counts: raised leucocyte count,
            c) The pelvis                                        Plain X-ray abdomen:
     Pathological                                                   Dilated gas-filled loops of bowel (paralytic ileus)
        Adhesions around the inflamed organ                         Pneumoperitoneum
        Retarded peristalsis of the affected bowel               Serum amylase estimation:
        The greater omentum, by enveloping and                      To differentiate acute pancreatitis
           becoming adherent to inflamed structures
                                                                   Ultrasound and CT scanning
     Surgical
                                                                   Peritoneal diagnostic aspiration: the aspirated fluid is
        Drainage of intra-abdominal collections                    examined macroscopically and microscopically.
Factors for spread of infection                                    Macroscopic appearance of the fluid aspirated
     Perforation of hollow viscus                                   Bile: perforation of peptic ulcer, gall bladder,
        E.g.: appendicular perforation or perforated peptic             common bile duct
           ulcer may cause gush of contents into the                  Blood: ruptured ectopic gestation
           peritoneal cavity, spreading over a large area             Bloody fluid: acute pancreatitis, gangrene of
     Stimulation of peristalsis                                         small bowel
        By the ingestion of food, or water, and                     Clear: intestinal obstruction, tuberculosis,
           administration of purgatives or enemata, which                 enterocolitis, rupture of hydatid or ovarian cyst
           enhances peristalsis of the bowels                         Pus with odour: perforation of viscus
     The virulence of the organism                                  Pus-odourless: perforation of peptic ulcer,
     Young children, who have an ill developed greater                  salpingitis, acute appendicitis
       omentum                                                     Microscopy of the fluid may show neutrophils,
     Disruption of localized collections                           R.B.C., or bacteria by Gram’s or AFB staining
        Injudicious and rough handling, e.g., appendix
           mass or pericolic abscess
                                                                TREATMENT
     Deficient natural resistance (‘immune deficiency’)       The principles of treatment
        Steroids
        AIDS                                                     Resuscitation
        Old age                                                  Specific treatment for the cause
Yogi Ram’s lectures on Surgery
                                                   The peritoneum, omentum, mesentery and retroperitoneal space 45

        Surgery                                                     Systemic complications:
        Conservative                                                   Bacteraemic / endotoxic shock
        Peritoneal lavage and drainage                                 Multi-organ failure
Resuscitation                                                            Bronchopneumonia/respiratory failure.
                                                                         Renal failure
   IV fluids                                                           Bone marrow suppression
   Antibiotics                                                      Abdominal complications:
   Analgesics                                                          Paralytic ileus
   Gastrointestinal decompression: by naso-gastric                     Adhesions and small bowel obstruction
     aspiration
                                                                         Portal pyaemia/ liver abscess
   Monitoring and support of vital systems (cardiac,
                                                                         Intraperitoneal residual abscess
     pulmonary and renal)
Specific treatment of the cause                                    RESIDUAL ABSCESS
   Depends upon the aetiology of peritonitis –                   (INTRAPERITONEAL ABSCESS)
      Surgery
                                                                   Sites
      Non-operative treatment
Surgery                                                               Subphrenic space
                                                                      Paracolic
Timing of operation
                                                                      Right iliac fossa
  In any case of doubt, it is always better to look and see         Pelvic
    rather than to ‘wait and see’; for greater numbers of
    patients die from delay than from an ‘unnecessary’             Clinical features
    laparotomy.
                                                                      General features of infection
Indications
                                                                         Pyrexia (often low-grade)
 Perforation of the viscus (appendicitis, diverticulitis,              Tachycardia
   peptic ulcer, enteric fever),                                      Local features
 Gangrenous viscus (cholecystitis, strangulated bowels)                Tenderness over the abscess
 Spreading peritonitis                                                 Later stages: a palpable and tender mass
Procedure                                                                Vague systemic disturbance (lassitude, anorexia)
   Surgery after resuscitation                                            with masked local features
   Laparotomy and dealing with the diseased organ:
                                                                   Investigations
     closure of perforation, removal of infected organ,
     resection of gangrenous viscera etc.                             Leucocyte count
   Peritoneal lavage and drainage                                   Ultra sound scan / CT scan:
      After laparotomy and dealing with the offending                  To diagnose the site and size of the abscess
          viscus, the peritoneal cavity is washed with saline            To monitor the course of the abscess
          and abdomen is closed leaving a drain
Non-operative treatment                                            Treatment
Indications                                                        Medical treatment
   Peritonitis due to pancreatitis or salpingitis, or               Indications: small abscess
   Primary peritonitis of streptococcal or pneumococcal
     origin (if the diagnosis can be made with certainty).
                                                                   Surgery
                                                                      Indications:
Prognosis                                                                Failure to resolve
Mortality depends upon                                                   Increasing in size
 Degree and duration of peritoneal contamination and
   associated metabolic sequelae                                   Procedure
 Age of the patient                                                 Extra peritoneal drainage of abscess:
 General health of the patient                                         With conservative treatment for a few days, the
 Nature of the underlying cause                                           abscess becomes adherent to the abdominal wall,
Generalised peritonitis carries a bad prognosis. With                       so that it can be drained without opening the
modern treatment it carries a mortality of about 10 – 40%.                  general peritoneal cavity. Cautious blunt finger
                                                                            exploration should be done to minimize the risk
Complications of peritonitis                                                of an intestinal fistula

                                                                                            Yogi Ram’s lectures on Surgery
46 The peritoneum, omentum, mesentery and retroperitoneal space

   Ultrasound or CT guided drainage is also useful              Left: the falciform ligament.
                                                                  Right: chest wall
Pelvic abscess                                                    Below: opens into general peritoneal cavity, but
Anatomy of pelvic space                                             usually closed due to adhesions
The pelvic space is formed in the male by rectovesical         Causes of abscess
space and in the female by rectovaginal (Douglas) pouch           Cholecystitis, perforated duodenal ulcer, duodenal cap
Causes                                                              `blow out' following gastrectomy and appendicitis.
(The pelvis is the commonest site of an intraperitoneal        2) Left superior intraperitoneal (left
abscess.)                                                      subphrenic) space
 Diffuse peritonitis                                         Boundaries
 Pelvic infections:
     Acute appendicitis and acute salpingitis                   Above: diaphragm,
     Anastomotic leakage following large bowel and              Behind: left triangular ligament and the left lobe of the
          rectal surgery.                                           liver, the gastrohepatic omentum and anterior surface
                                                                    of the stomach
Clinical features                                                 Right: the falciform ligament and
   Diarrhoea and the passage of mucus in the stools.            Left: gastrosplenic omentum, spleen and diaphragm
   Tenesmus                                                  Cause of abscess
   Per rectal examination: bulging of the anterior rectal
     wall                                                         Following operations on the stomach, the tail of the
                                                                    pancreas, the spleen or the splenic flexure
Course
                                                               3) Right inferior (posterior) intraperitoneal
   May burst into the rectum  natural recovery
                                                               (right subhepatic) space (Rutherford
Treatment                                                      Morison's pouch)
   Incision and drainage                                     Boundaries
      Through the posterior fornix in females
                                                                  Anterior: the liver and the gall bladder,
      Through the rectum in the males, if the abscess is
          pointing into the rectum.                               Posterior: the upper part of the right kidney and
                                                                    diaphragm.
   Laparotomy is not necessary.
                                                                  Above: liver, inferior coronary ligament
Subphrenic abscess                                                Below: transverse colon and hepatic flexure.
                                                                  Right: the right lobe of the liver and the diaphragm.
Anatomy of subphrenic spaces                                      Left: the foramen of Winslow and below this lie the
The space underneath the diaphragm is divided into four             duodenum.
intraperitoneal and three extra peritoneal spaces by various   Causes of abscess
peritoneal attachments to the liver. These are –
 Intraperitoneal                                                 Appendicitis, cholecystitis, perforated duodenal ulcer
      Right superior intraperitoneal                               or following upper abdominal surgery.
      Left superior intraperitoneal                          It is the deepest space of the four and the commonest site
                                                               of subphrenic abscess
      Right inferior intraperitoneal
      Left inferior intraperitoneal                          4) Left inferior (posterior) intraperitoneal
 Extra peritoneal                                            (left subhepatic) space (lesser sac)
      Right and left perinephric spaces                      Boundaries
      Bare area of liver
                                                                  Above: inferior surface of liver and left triangular
1) Right superior (anterior) intraperitoneal                        ligament
(right subphrenic) space                                          Anterior: posterior surface of liver, lesser omentum,
Boundaries                                                          stomach, anterior leaf of greater omentum
                                                                  Posterior: diaphragm, pancreas, transverse mesocolon,
   It lies between the diaphragm and the right lobe of the        transverse colon, posterior layer of greater omentum
     liver.
                                                                  Below: fold of greater omentum
   Superior: anterior layer of the coronary and the right
                                                                  Left: hilum of spleen
     triangular ligaments,
                                                                  Right: epiploic foramen
   Posterior: liver
   Anterior: diaphragm and anterior abdominal wall           Causes of abscess
Yogi Ram’s lectures on Surgery
                                                 The peritoneum, omentum, mesentery and retroperitoneal space 47

   The commonest cause of infection is acute                           If swelling is not apparent, CT is done to identify
     pancreatitis.                                                         the site and an anterior abscess is explored by an
   A perforated gastric ulcer may rarely cause a                         anterior subcostal approach and a posterior
     collection here because the potential space is                        abscess is explored through the bed of l2th rib and
     obliterated by adhesions.                                             care taken to avoid pleural injury
Extraperitoneal spaces                                           SPECIAL FORMS OF PERITONITIS
   Right and left extraperitoneal which are terms given to
     perinephric abscesses                                       Postoperative peritonitis
   Midline extraperitoneal: `bare' area of the liver
   Cause of the abscess: amoebic abscess (the
                                                                 Causes
     commonest cause) and pyogenic liver abscess                    Anastomotic leak (usually)
                                                                    Infection from appendicular stump, vault sepsis etc
Clinical features
                                                                 Clinical features
Features due to abscess                                             Deteriorating condition of the patient, with raised
   Vague systemic disturbance (lassitude, anorexia) with            pulse and peripheral circulatory failure
     masked local features                                          Local symptoms and signs are ill defined
   Pyrexia, tachycardia                                        Investigations
   `Pus somewhere, pus nowhere else, pus under
     diaphragm – Rutherford Morrison’                               Blood: leucocytosis
   Local –                                                        Plain X ray abdomen in erect posture
      Anterior abscess: tenderness, rigidity or palpable          Ultra sound scan
         swelling right hypochondrium                               Serum amylase
      Palpable liver due to displaced liver (more often it     Treatment
         is fixed by adhesions)                                     Same as general peritonitis
      Collapse of the lung or basal effusion or                   The anastomotic leak must be dealt with by surgery
         empyema
                                                                 Peritonitis in senile patient
Investigations
                                                                    Tenderness is usually well localised
   Blood count: leucocytosis                                      But guarding and rigidity are less marked because the
   Plain X ray abdomen                                              abdominal muscles are thin and weak.
      Presence of gas with fluid level under the
         diaphragm                                               Bile peritonitis
   Pleural effusion.
   On screening, fixed and elevated (tented) diaphragm         Causes
   Ultrasound or CT scanning                                      Perforated duodenal ulcer
                                                                    Traumatic perforation of duodenum
Differential diagnosis                                              Postoperative
   Pyelonephritis,                                                   Stump blow-out
   Amoebic abscess,                                                  Anastomotic leak of bile duct surgery
   Pulmonary collapse and                                            Following cholecystectomy
   Empyema                                                           Leak from cystic duct stump
                                                                       Injury to bile duct
Treatment                                                              Leak from bed of gall bladder (cholecysto-hepatic
                                                                          duct)
   Antibiotics
                                                                    Post ERCP procedures
   If suppuration occurs
                                                                    Following perforation or gangrene of gall bladder
      Percutaneous insertion of a drainage tube under
          ultrasound or CT control (caution is exercised to      Treatment
          prevent entry into the pleural cavity)                    Depends upon the cause
   Surgery
      If swelling is obvious, incision and drainage of         Meconium peritonitis
          the abscess through the point of maximum
          tenderness or through an area of erythema or           Pathology
          brawny induration is done                                 It manifests in late intrauterine life or neonatal period.

                                                                                           Yogi Ram’s lectures on Surgery
48 The peritoneum, omentum, mesentery and retroperitoneal space

     It is due to sterile meconium, leaked into the              If no other cause for peritonitis is discovered,
     peritoneal cavity from an intestinal perforation             laparotomy and thorough peritoneal lavage is done.
     Inflammatory exudate causes matting of intestinal
     loops.                                                   Primary streptococcal peritonitis
   After six hours of birth, bacterial peritonitis occurs
     and later, the meconium becomes calcified.
                                                              Types
                                                                 In children
Clinical features                                                In adults
   Tense abdomen in a new born with vomiting
                                                              Of infants and children
   Failure to discharge meconium.
                                                                 The clinical presentation and treatment are similar to
Differential diagnosis                                             those of pneumococcal peritonitis, but the mortality is
   Neonatal intestinal obstruction.                              high
Radiography                                                   Of adults
Meconium peritonitis can be diagnosed by radiography of          Rare
the foetus in utero 2 days before birth                          Mortality is very high
 Free air in the peritoneal cavity
 Fluid levels                                               Peritonitis following abortion/parturition
 Calcification on the surface of the liver or the spleen
                                                              Causes
Treatment                                                        Perforation of uterine vault during procedures for
   Laparotomy and closure of the perforation and                 termination of pregnancy
     drainage of the peritoneal cavity                           Puerperal infection
Prognosis                                                     Clinical features
   Bad                                                         Rigidity is rarely present
                                                                 The lochia is offensive
Pneumococcal peritonitis
                                                                 Diarrhoea is common
Pathology                                                     Treatment
Types                                                            Same as peritonitis
   Primary (common)                                            Posterior colpotomy, if pelvic abscess forms
   Secondary to pneumonia.                                  Prognosis
Primary pneumococcal peritonitis                                 With modern treatment, the mortality has fallen to less
Source of infection                                                than 10 per cent.

   Via the vagina and Fallopian tubes in undernourished     Familial Mediterranean fever (periodic
     girls of 3 – 6 years of age.                             peritonitis)
   In males, the infection is blood-borne from the upper
     respiratory tract or the middle ear.                     Incidence
Clinical features                                             Familial and seen in Arabs, Armenians and Jews; other
                                                              races are occasionally affected.
   Features of generalized peritonitis with predominant
     features of pelvic peritonitis – diarrhoea and           Aetiology
     strangury.                                                  Not known.
   Associated features of pneumonitis
                                                              Clinical features
Differential diagnosis                                           Recurrent abdominal pain and tenderness, mild
   Acute appendicitis:                                           pyrexia with pain in the thorax and joints.
      A leucocytosis of 30,000/mm3 suggests                    The attack lasts 24 – 72 hours
        pneumococcal peritonitis.
   Acute pneumonia:
                                                              Treatment
      Rigidity is absent.                                      Colchicine may prevent recurrent attacks
Treatment                                                     TUBERCULOUS PERITONITIS
   Conservative, if diagnosis is made with certainty
                                                              Pathology
Yogi Ram’s lectures on Surgery
                                                    The peritoneum, omentum, mesentery and retroperitoneal space 49

Types                                                                  X-ray chest for any lesion in lungs
   Acute                                                             Ultra sound scan: to exclude other causes of ascites
   Chronic                                                           Laparoscopy: extremely useful investigation. It
                                                                         differentiates various exudative forms of ascites
Acute tuberculous peritonitis                                       Differential diagnosis
It is rare and presents like acute bacterial peritonitis            This condition has to be differentiated from other forms of
                                                                    ascites –
Treatment
                                                                     Cirrhosis
   Laparotomy and the fluid is evacuated, omentum is               Carcinoma peritonei
     removed for histological confirmation of the diagnosis          Congestive cardiac failure
     and the wound closed without drainage                           Hypoprotinaemia
   Anti tuberculous treatment postoperatively                      Nephritis
Chronic tuberculous peritonitis                                     Treatment
Pathology                                                              Anti tuberculous treatment

Source of the infection                                             Encysted form
   Abdominal: tuberculosis of mesenteric lymph nodes,             Pathology
     ileocaecal region, tuberculous pyosalpinx                      It is a localised ascitic form.
   Blood-borne: from pulmonary tuberculosis                       Clinical features
Pathogenesis                                                           A localised intra-abdominal cystic swelling
The disease manifests with multiple tubercles on the
                                                                    Differential diagnosis
peritoneum  fluid exudation (rich in proteins). This leads
to any of the following conditions –                                   Mesenteric cyst in children
 1) Accumulation of fluid in peritoneal cavity: ascitic              Ovarian cyst in females
     form                                                           Treatment
 2) Localised collection in the peritoneal cavity:
                                                                       Laparotomy and evacuation of encapsulated collection
     encysted form
                                                                         of fluid and anti tuberculous treatment
 3) Fibrinous adhesions in the peritoneal cavity: plastic
     (fibrous) form                                                 Fibrous form (plastic peritonitis)
 4) Caseation in the peritoneal cavity: purulent form             Pathology
Ascitic form                                                           Widespread adhesions  matted coils of intestine
Clinical features                                                   Clinical features
   Insidious onset                                                   Sub acute or acute intestinal obstruction.
   General features of tuberculosis                                  Features of `blind loop': steatorrhea and wasting
   Progressive, painless ascites                                     Recurrent attacks of abdominal pain.
   On palpation,                                                     Palpable swelling
      Abdomen is felt doughy
                                                                    Treatment
      A transverse solid mass of rolled-up greater
          omentum is palpated.                                         Laparotomy and relief of the obstruction
                                                                       Associated strictures of bowel are also treated
Investigations                                                         Anti tuberculous treatment
   Ascitic fluid analysis:
      Clear, pale yellow, and rich in lymphocytes
                                                                    Purulent form
      The specific gravity more than 1.020                        Pathology
      Protein is more than 25G/L                                     Rare, usually due to tuberculous pyosalpinx
   Microbiological examination:                                      Amidst a mass of adherent intestine and omentum,
      AFB staining (rarely the organism is found)                      tuberculous pus is present  may rupture into bowel
      Culture and guinea-pig inoculation                               or skin faecal fistula
   Montoux test:                                                  Treatment
      In a child, positive test suggests tuberculosis and
         negative test excludes tuberculosis.                          Anti tuberculous treatment
      In adults, it has no value                                     Evacuation of cold abscesses


                                                                                              Yogi Ram’s lectures on Surgery
50 The peritoneum, omentum, mesentery and retroperitoneal space

   If a faecal fistula forms, closure of the fistula +         Clinical features due to the cause
     treatment of associated stricture
                                                                 The common causes of ascites in surgical practice are –
Prognosis                                                         Tuberculosis of the peritoneum
   Poor                                                         Carcinoma peritonei
                                                                  Cirrhosis of liver
ASCITES                                                           (In general, the commonest cause is congestive
Definition                                                           cardiac failure)
                                                                  Congestive cardiac failure
Abnormal collection of fluid in the peritoneal cavity                 Engorged neck veins, tender hepatomegaly with
                                                                         hepato-jugular reflux, paedal oedema and
Mechanism of ascites                                                     tachycardia
The ascites forms due to one of the following causes –            Cirrhosis of the liver
 Increased hydrostatic pressure in the capillaries                  Caput medusae, splenomegaly with the history of
 Reduced oncotic pressure in the capillaries                           oesophageal varices
 Increased secretion due to increased capillary                 Carcinoma peritonei
    permeability                                                      Rapid ascites, palpable supraclavicular nodes,
 Decreased absorption                                                  rectal shelf of Blumer, with or without a mass in
                                                                         the abdomen (detected by dipping method)
Increased hydrostatic pressure in the                             Tuberculous peritonitis
capillaries                                                           Doughy abdomen with rolled up omentum in the
The causes are –                                                         epigastrium and general features of tuberculosis
 Congestive cardiac failure                                            or pulmonary tuberculosis
 Cirrhosis and portal vein thrombosis                           Meigs syndrome (solid fibroma of ovary with serosal
 Constrictive pericarditis                                         effusions) or Pick’s disease (constrictive pericarditis)
 Budd-Chiari syndrome                                               Ascites associated with bilateral pleural effusion
 Generalised Na (water) retention                               Hypoprotinaemia and congestive cardiac failure
                                                                      Ascites associated with anasarca
Lowered oncotic pressure of plasma
The causes are –                                                 Differential diagnosis of ascites
 Hypoprotinaemia
                                                                    Large ovarian cyst
 Nutritional
                                                                       Differentiated by ruler sign.
 Nephrotic syndrome
                                                                       Tympanitic epigastrium and flanks in ovarian cyst
 Cirrhosis
 Protein losing enteropathy                                    Investigations
 Malabsorption
                                                                    Urine analysis: albuminuria suggests nephrotic
Increased permeability of capillaries                                 syndrome.
The causes are –                                                    X-ray of chest
 Peritonitis (acute and chronic)                                     For pulmonary tuberculosis or secondary
 Carcinomatosis peritonei                                                deposits, cardiac enlargement, mediastinal mass
 Pancreatitis                                                            and pleural effusions.
                                                                    Blood count and protein estimation.
Impaired absorption of peritoneal fluid
                                                                    Peritoneal fluid analysis
   This occurs usually in thoracic duct obstruction                  Blood stained (tuberculosis, malignancy)
Clinical features                                                      Cell count and for malignant cells
                                                                       Gram’s stain
   Distended abdomen with fullness of the flanks which                    AFB staining in selected cases
     are dull to percussion                                            Protein estimation*
   Umbilicus is flat or everted and pushed downwards                      More than 25 G/L: exudates (infections,
     (pelvic mass causes shift of umbilicus upwards)                           malignancy)
   If fluid is less than 300 ml = Puddle’s sign (dullness                 Lesser than 25 G/L: transudate (increased
     around umbilicus in knee-elbow position)                                  hydrostatic pressure or decreased oncotic
   If fluid is around 1500 ml = Shifting dullness                            pressure)
   If fluid is in large quantities, shifting dullness is not         *SAAG (serum-ascites albumin gradient =
     elicited and fluid thrill is diagnostic
Yogi Ram’s lectures on Surgery
                                                The peritoneum, omentum, mesentery and retroperitoneal space 51

         albumin in serum minus albumin in ascitic fluid)          Posterior mediastinal lymphomas
      More than 10 = transudate                                  Filariasis
      Lesser than 10 = exudate                                   Rarely, due to cirrhosis, tuberculosis, nephrotic
   Ultra sound scan                                                syndrome, abdominal trauma (including surgery),
      For presence of fluid in the peritoneal cavity               constrictive pericarditis, sarcoidosis and congenital
      For cirrhosis and                                            lymphatic abnormality.
      For any mass in the pelvis or ovaries                   Prognosis
   Laparoscopy
                                                                   Poor unless the underlying condition can be cured.
      Multiple nodules on the peritoneum and greater
         omentum (differential diagnosis: tuberculosis,         Treatment
         secondaries, fat necrosis, hydatidosis)                   Treatment of ascites
      Nodules can be taken for histopathological                 Fat-free diet with medium-chain triglyceride
         examination                                                 supplements.
Treatment                                                       Peritoneal loose bodies (peritoneal mice)
   Treatment of the cause                                     Causes
   Dietary sodium restriction to 200 mg per day may be
     helpful                                                       Detached appendix epiploica following axial rotation
   Diuretics                                                       followed by necrosis of its pedicle
      Spironolactone + loop diuretics                            The hyaline bodies of fat necrosis in pancreatitis
          Complications: hyperkalemia, renal failure,         NEOPLASMS OF THE PERITONEUM
              gynecomastia
   Paracentesis abdominis
                                                                (CARCINOMA PERITONEI)
      Unless other measures are taken, the fluid soon         Pathology
         re-accumulates and repeated tapings remove
         valuable protein                                       Types
   Paracentesis with IV albumin infusion                         Primary
   Permanent drainage of ascitic fluid in cirrhosis by              Mesothelioma
     surgery
                                                                   Secondary deposits, from carcinoma of
Peritoneovenous shunt (e.g. LeVeen or Denver)                         Stomach,
Indications                                                           Colon,
 In rare cases where ascites accumulates rapidly after              Ovary
   paracentesis in a fit patient                                      Breast and bronchus.
Procedure                                                       Mesothelioma
 A catheter (e.g. of silicone) with a valve is placed
                                                                   It is a highly malignant tumour.
   connecting peritoneum to a central vein (e.g. internal
   jugular).                                                       Aetiology: asbestosis
                                                                   Treatment
Complications
                                                                      Alkylating agents
   Cardiac overload  congestive cardiac failure
   DIC (disseminated intra vascular coagulation)              Secondaries peritoneum
Other operations for ascites with cirrhosis                     Pathology
   A) Porta caval shunt operation, which are reserved for     The peritoneum is studded with
     those patients who are fit to undergo surgical              Discrete nodules
     intervention                                                Plaques or
   B) Liver transplantation:                                   Diffuse adhesions giving rise to ‘frozen pelvis’.
      Indications: drug resistant ascites with                The peritoneal cavity is filled with clear, straw-coloured or
          deteriorating liver function                          blood-stained ascitic fluid.
   C) TIPSS: it is not advised for treatment of ascites
                                                                Differential diagnosi of nodules on
Chylous ascites                                                 peritoneum
This condition is rare.                                            Secondary deposits
                                                                   Tuberculosis (tubercles are greyish and translucent)
Causes

                                                                                         Yogi Ram’s lectures on Surgery
52 The peritoneum, omentum, mesentery and retroperitoneal space


   Fat necrosis (opaque nodules)                              Secondary
   Peritoneal hydatids                                           To an adhesion of the omentum to an old focus of
   Other rare causes: talc granuloma, splenosis,                    infection, or to a hernia.
     actinomycosis, encapsulated foreign bodies              Clinical features
Treatment of secondaries of peritoneum                          Obese males are commonly affected
                                                                They present with acute abdominal pain, mistaken for
   Systemic chemotherapy                                        acute appendicitis
   Intraperitoneal chemotherapy with cisplatin,               On examination –
     mitomycin C or methotrexate after drainage of ascites         Tender lump in upper abdomen
   Tamoxifen for breast cancer secondaries                       Features of bacterial peritonitis in cases of
Pseudomyxoma Peritonei                                                gangrenous omentum.
                                                             Treatment
   Rare
   Sex: frequently in females.                                Laparotomy and excision of the mass.
   The abdomen is filled with a yellow jelly               Cyst of the greater omentum (omental
   It is locally malignant but does not give rise to
                                                             cyst)
     extraperitoneal metastases.
Aetiology                                                    Causes
   Mucinous cystic tumours of the ovary                       Lymphatic cysts
   Mucocele of appendix and                                   Pseudo pancreatic cyst
   Colloid carcinoma of rectum                                Hydatid cyst
Clinical features                                            Other diseases of greater omentum
   Painless abdominal distension with out shifting
                                                             Greater omentum is affected by any disease affecting the
     dullness.
                                                             peritoneum, but mostly affected in tuberculosis and
Investigations                                               malignancy, when the omentum is scrolled like a cake.
   Ultrasound and CT scanning                              Surgical applications of greater omentum
   Colonoscopy to rule out the lesions in the colon
Treatment                                                       Sealing the perforation (omental plugs)
                                                                Filling of cavities –
   Laparotomy and masses of jelly are scooped out.               E.g., after excision of large hydatid cyst of liver
   The appendix / ovarian tumour is excised                   Repair of vesico-vaginal fistula and high level recto
   In recurrence cases –                                        vaginal fistula by interposing it between the two
      Radioactive isotopes or intraperitoneal                   viscera
          chemotherapy                                          Arrest of bleeding as a haemostatic plug, especially in
                                                                  the tears of liver
THE GREATER OMENTUM
                                                                To cover raw surfaces in the abdominal cavity
Functions                                                       Extra-abdominal uses
                                                                   Perfusion of ischemic limbs, e.g., in TAO,
Rutherford Morison called the greater omentum as `the                  omentum is brought subcutaneously to lower
abdominal policeman'.                                                  limbs through femoral canal after pediculation
 It limits intraperitoneal infective and other
    pathological processes                                   THE MESENTERY
 E.g., acute appendicitis forming appendicular mass
     The bleeding from small lacerations of spleen or      Anatomy
        liver are controlled by greater omentum adhering     The mesentery of small bowel stretches from duodeno-
        to the site of laceration                            jejunal junction to ileo-caecal junction. It contains the
Torsion of the omentum                                       jejunal branches of superior mesenteric artery and vein, the
                                                             lacteals from the bowel and mesenteric lymph nodes.
It is rare
                                                             Injuries
Aetiology
   Primary                                                 Causes
Yogi Ram’s lectures on Surgery
                                                  The peritoneum, omentum, mesentery and retroperitoneal space 53

   Penetrating injury of abdomen                                     across the mass.
   Blunt abdominal trauma
   Seat-belt syndrome
                                                                  Acute nonspecific mesenteric adenitis
      If a car accident occurs when a seat belt is worn,        Aetiology
         sudden deceleration can result in a torn mesentery
         leading to haemoperitoneum                                  ? Yersinia infection of the ileum.
      Usually, it is associated with rupture of the                ? Virus infection
         intestine.                                               Clinical features
Investigations                                                       Incidence:
   X-ray abdomen in erect posture                                     Children, (unusual after puberty)
   Ultra sound scan abdomen                                        Central abdominal pain associated with vomiting
   Diagnostic peritoneal lavage:                                   It mimics acute appendicitis in children (If vomiting is
      A sub umbilical catheter is passed into the                    absent, it is more likely to be a case of mesenteric
         peritoneal cavity. One litre of normal saline is run          adenitis than appendicitis)
         into the peritoneum and then drained off by                 There may be past history of recurrent attacks of the
         placing the bag and tubing below the patient's                similar problem
         abdomen. The presence of blood (more than 100               On examination
         000 R.B.C/mm3), bile or intestinal contents is an              Pyrexia (rarely, it exceeds 38.3°C)
         indication for laparotomy.                                     Tenderness is along the line of the mesentery.
                                                                        Shifting tenderness (differentiates from
Treatment
                                                                            appendicitis)
   Small wounds and wounds in the long axis are                            After laying the patient on the left side for a
     sutured.                                                                    few minutes, the maximum tenderness moves
   Large and transverse, tears where the blood supply to                       to the left)
     the neighbouring intestine is cut off, resection of the            Brucellosis should be suspected if there is
     affected gut is done.                                                  associated enlargement of cervical, axillary and
                                                                            inguinal nodes
Swellings of mesentery
                                                                  Investigations
Classification                                                       Leucocyte count: 10,000 –12,000/mm3 on the first
   Cystic                                                            day of the attack, and falls on the second day
      Mesenteric cyst                                              Ultra sound scan
      Cysts of Wolffian and Müllerian remnants
                                                                  Treatment
      Dermoid cysts
      Sero sanguineous cyst of mesentery                           When the diagnosis can be made with certainty
      Hydatid cyst                                                    Bed rest.
      Cold abscess of mesentery                                    If acute appendicitis cannot be excluded
   Solid                                                              Laparoscopy or appendicectomy
      Lymph node masses                                         Tuberculosis of the mesenteric lymph
          Inflammatory
                                                                  nodes
             Non-specific
             Tuberculous                                        Pathology
          Neoplastic
             Primary
                                                                  Source of infection
             Secondary                                             Peyer's patches.
      Mesenchymal tumours                                       Clinical presentation
          Lipoma,
                                                                     1) Demonstrated radiologically due to calcified nodes:
          Fibroma
                                                                        To be distinguished from other calcified lesions,
          Sarcoma
                                                                           e.g. renal or ureteric stones
Clinical features of mesenteric mass                                 2) As general disturbance:
   Swellings move perpendicular to the line of                        Loss of appetite
     mesentery.                                                         Loss of weight
   Restricted mobility in the line of mesentery.                      Evening pyrexia
   Resonance around the mass with a band of resonance              3) Non-specific abdominal pain


                                                                                           Yogi Ram’s lectures on Surgery
54 The peritoneum, omentum, mesentery and retroperitoneal space

   4) Features resembling acute appendicitis                  As a painless abdominal swelling with features of
   5) As intestinal obstruction, due to kinking of small        mesenteric swelling
     intestine adhered to a caseating node                      As recurrent attacks of abdominal pain with or without
   6) As pseudo mesenteric cyst, due to cold abscess in         vomiting
     the mesentery.                                                Due to angulation of the bowel over the cyst, or
   7) As ileocaecal lymph nodal mass                                due to torsion of the mesentery
Investigations                                                  As acute abdominal pain due to
                                                                   Torsion
   Ultra sound /CT scan                                          Rupture of the cyst
Treatment                                                          Haemorrhage into the cyst or
   Anti tuberculous treatment                                    Infection
   In cold abscess, the tuberculous pus should be          Investigations
     aspirated without soiling the peritoneal cavity            Barium meal follow-through or enteroclysis:
Mesenteric cysts                                                   The bowel is displaced around the cyst or the
                                                                      lumen of the bowel may be narrowed
Classification                                                  Ultra sound scan:
   Chylolymphatic cysts                                          Cystic mass
   Enterogenous cysts                                         I.V.P
   Cysts of urogenital remnant                                Cystogram
   Dermoid (teratomatous cyst)                             Treatment
Chylolymphatic cyst                                             Chylolymphatic cysts: enucleated in toto
It is the commonest of mesenteric cysts                         Enterogenous cyst:
                                                                   Enucleation must not be attempted
Aetiology                                                          If short segment of the intestine is involved:
   Probably from congenitally misplaced lymphatic                    resection of the cyst with the adherent portion of
     tissue that has no communication with the lymphatic               the intestine, followed by intestinal anastomosis
     system                                                        If a large segment of intestine is involved,
Pathology                                                              cystoenterostomy is done
                                                                Marsupialisation is not advised because of the fear of
Site: mesentery of the ileum
                                                                  a fistula or recurrence
 It is filled with clear lymph or chyle
 Usually unilocular and solitary                           Cysts arising from a urogenital remnant
 Occasionally, the cyst attains a large size                  Usually, they are retroperitoneal but may project
 It has an independent blood supply, thereby                    forward into the mesentery and present as mesenteric
     enucleation is possible without the necessity of             cyst
     resection of gut
                                                             Differential diagnosis of mesenteric cysts
Enterogenous cyst
Aetiology                                                       Serosanguinous cyst
                                                                Tuberculous abscess of the mesentery
   A diverticulum or a sequestrated congenital                Hydatid cyst of the mesentery
     duplication of the intestine becomes a cyst
Pathology                                                    NEOPLASMS OF THE MESENTERY
   It has a thicker wall than a chylolymphatic cyst, and   Classification
     lined by mucous membrane
   It contains colourless or yellowish-brown mucinous         Benign
     fluid                                                         Lipoma
   It has a common blood supply with intestine; hence,           Fibroma
     removal of the cyst needs resection of the related            Fibromyxoma
     portion of intestine                                       Malignant:
Clinical features of a mesenteric cyst                             Lymphoma
                                                                   Secondary carcinoma
   Age: 10 – 20 years (rarely between 1 – 10 years)
Modes of clinical presentation                               Treatment

Yogi Ram’s lectures on Surgery
                                                The peritoneum, omentum, mesentery and retroperitoneal space 55




   Resection with the adjacent intestine.                     Treatment
   In inoperable cases, radiotherapy                             Excision through a trans-peritoneal incision
THE RETROPERITONEAL SPACE                                       Idiopathic retroperitoneal fibrosis
Retroperitoneal haematoma                                          Discussed in the chapter on diseases of the kidney
Causes                                                          Primary retroperitoneal neoplasms
   Acute pancreatitis
                                                                Classification
   Bleeding from retroperitoneal tissues or organs
      Fracture spine                                             Mesenchymal tumours
      Leaking abdominal aneurysm                                    Lipoma
      Ruptured kidney                                               Soft tissue sarcoma
Treatment                                                       Pathology
   Resuscitation                                              Retroperitoneal lipoma
   Treat the cause                                               Sex: commonly females
                                                                   Sometimes, it is very big
Retroperitoneal abscess
                                                                   Can undergo myxomatous degeneration, (seen only in
Causes                                                               retroperitoneal lipoma)
                                                                   It is often malignant (liposarcoma) and may increase
   Infected haematoma                                              rapidly in size
   Infections of kidney or spine
      Tuberculosis                                            Retroperitoneal sarcoma
      Non-specific                                               It is fibrosarcoma and presents with signs similar to a
Treatment                                                            retroperitoneal lipoma

   Drainage of the abscess                                    Clinical features of retro peritoneal tumours
      Open method                                                Swelling abdomen with or with out pain
      Guided aspiration                                             Fixed, does not fall on knee-chest position, does
   Treat the cause                                                     not move on respiration, tympanitic
                                                                   Features due to obstruction
Retroperitoneal cysts                                                 Subacute intestinal obstruction
                                                                      Hydronephrosis
Causes
   Cysts of urogenital remnant                                Differential diagnosis
   Teratoma or dermoid cysts                                     Neoplasm of the kidney
                                                                   Hydronephrosis
Clinical features
   A large cystic swelling in the abdomen                     Investigations
                                                                   Ultra sound/CT scan
Differential diagnosis
                                                                   I.V.P
   Hydronephrosis
   Mesenteric cyst                                            Treatment
   Ovarian cyst                                                  Laparotomy and excision: if complete removal is not
                                                                     possible, debulking is done followed by radiotherapy
Investigations
   Ultra sound / CT scanning
   I.V.P




                                                                                         Yogi Ram’s lectures on Surgery
56 The spleen



Chapter 6

                                             THE SPLEEN
ANATOMY                                                               They are present in 20% of people. They are
                                                                        hamartomata. Splenunculi are single or multiple
   It measures 1x 3x 5 inches (2.5 x 7.5 x 12.5                       accessory spleens found near hilum, ligaments of
     centimetres) (size of a clenched fist). It weighs 200G             spleen, behind the tail of pancreas and in the
     (7 ounces). It lies between 9th and 11th ribs on left side.        mesocolon.
     Its long axis lies along the line of 10th rib.                   They become hyperplastic after splenectomy and take
   It is developed from the dorsal mesogastrium.                      the function of spleen. They are found at autopsy or at
   It has red and white pulp. The red pulp filters                    CT scanning.
     abnormal red cells and white pulp has an immune
     function.                                                     Cysts
FUNCTIONS OF SPLEEN                                                Pathology
                                                                   They are rare and they are formed from embryonal rests.
Earlier it was considered dispensable as it was considered         Types: dermoids, mesenchymal inclusion cysts
not essential for life. But, it performs some of the most
important functions in the body, namely –                          Differential diagnosis
 Immune function:                                                   False cysts following organisation of post traumatic
      Major site of immunoglobulin M (IgM)                            clots
          production                                                  Hydatid cyst
      Produces non-specific opsonins: tuftin and
          properdin (B and T cell antibodies), which
                                                                   Investigations
          sensitises bacteria and fungi for phagocytosis              Ultra sound scan
 Filtration of cellular and non-cellular material from           Treatment
     blood.
                                                                      Guided aspiration and sclerosant injection
 Removal of old R.B.C and platelets (culling)
 Pitting: removal of particulate inclusions (e.g.,               RUPTURE OF THE SPLEEN
     malarial parasite, nuclei) from R.B.C and returning the
     repaired R.B.C to the circulation.                            Causes
 Re-utilisation of iron removed from the haem of
     destroyed R.B.C.                                                 Blunt trauma to upper abdomen and left side of lower
 Pooling of platelets and blood: the pooled blood is                  chest
     pumped into circulation during shock to replace lost             Fall from a height without direct trauma to the
     blood volume. This volume contributed by spleen in                 abdomen in diseased spleens, e.g.; tropical
     humans is small (around 30 ml), but is large in lower              splenomegaly
     animals.                                                         Penetrating injuries of abdomen or lower chest
 Haematopoiesis in intra uterine life up to 5th month.
                                                                   Types of clinical presentation
INVESTIGATIONS                                                     The clinical presentation depends upon the type of the
   Ultra sound scan                                              injury and the speed of bleeding. The types of presentation
                                                                   of rupture of the spleen are –
   CT scan
                                                                    1) Severe initial shock with immediate fatality
   Radio-isotope scans with technetium 99m (99mTc)
                                                                    2) Shock with features of haemoperitoneum
   Haematological investigations to study associated
     haematological disorders                                       3) Delayed shock and haemoperitoneum
   LFT                                                           1) Severe initial shock with immediate fatality.
                                                                   This occurs usually due to avulsion of splenic pedicle
CONGENITAL DISEASES
                                                                   2) Shock with features of haemoperitoneum
Splenunculi                                                        General features of shock
Yogi Ram’s lectures on Surgery
                                                                                                         The spleen 57

   Increasing pallor, rising pulse rate, falling blood                 For multiple tears, enclosure in an absorbable
     pressure, cold clammy skin, deep sighing respiration,                 mesh bag
     restlessness and oliguria.
   Localised bruising over left upper quadrant                 Rupture of malarial splenomegaly
Local features of haemo-peritoneum                                  Trivial trauma can cause splenic rupture.
   Tenderness and guarding in the left upper quadrant             Identification of subcapsular haematoma and
   Pain radiating to left shoulder due to irritation of left        splenectomy saves grave complications
     dome of diaphragm by blood in the peritoneal cavity            Splenectomy is difficult because of adhesions between
      Kehr’s sign: the patient is asked to lie down                 spleen and diaphragm.
          supine and the foot end of the bed is elevated for     SPLENECTOMY
          ten minutes. The skin over the shoulder is tested
          for hyperaesthesia. In case of free intraperitoneal    Indications
          blood (e.g., rupture of liver or the spleen), this
          sign is elicited on the right or more commonly on         Trauma:
          the left shoulder                                            Following an accident or
   Distension of abdomen usually 2 – 3 hours after the               During a surgical operation, for example when
     accident due to reflex paralytic ileus and collection of              mobilizing the splenic flexure of the colon
     intra peritoneal blood                                         Removal en bloc with other surgeries
   Shifting dullness in 25% of cases                                 As a part of a radical gastrectomy
   Ballances’ sign: shifting dullness can be elicited in          As part of staging laparotomy for Hodgkin’s
     right flank and not elicited in left flank due to                lymphoma (now, not done)
     presence of clotted blood in the left flank.                   To reduce anaemia or thrombocytopenia in
3) Delayed shock and haemoperitoneum                                   Spherocytosis
                                                                       ITP
   Due to reactionary or secondary haemorrhage or due
     to rupture of a subcapsular haematoma                             Hypersplenism
                                                                    In association with shunt surgery for portal
Investigations                                                        hypertension.

   Plain X ray abdomen: the signs of splenic tear are          Procedure
      Obliteration of psoas shadow (Lt)
                                                                    Open technique
      Fracture of lower left ribs
                                                                       Abdominal
      Indentation of fundic gas bubble
                                                                       Abdomino-thoracic
      Obliteration of splenic outline
                                                                    Laparoscopic
   Ultra sound scan of abdomen
   Diagnostic peritoneal lavage                                Open splenectomy
   C.T. scan                                                   Incision
   Angiography
                                                                    Left paramedian/upper midline
Treatment                                                           Thoraco-abdominal incision through 8th or 9th space
                                                                       Done in massive splenomegaly cases with dense
   Resuscitation and assessment of associated injuries                   adhesions
   Surgery
      Laparotomy                                               Procedure
      Assessment of injury to spleen and other organs             After laparotomy, the anterior layer of gastrosplenic
      Collection of blood from peritoneal cavity for                ligament is opened, short gastric vessels ligated and
         auto transfusion if there is no associated injury to         cut. Care should be taken to avoid injury to the greater
         hollow viscus or liver (because the blood gets               curvature of the stomach during this procedure
         contaminated with bile or intestinal juices in             The anterior layer of lieno-renal ligament opened. The
         associated injuries)                                         splenic artery and the vein are ligated and cut after
   Splenectomy                                                      separating the pancreas tail from the hilum of the
   Splenorraphy (repair of splenic tears in children)               spleen
     depending upon the size of the tear                            Spleen removed after incising the posterior layer of
      Suturing                                                      lieno-renal ligament.
      Suturing on greater omentum                              Postoperative complications
      Excision of one pole of the spleen                          Haemorrhage, if a ligature slips off the splenic artery

                                                                                          Yogi Ram’s lectures on Surgery
58 The spleen


   Gastric dilatation                                                  Stab injuries
   Haematemesis due to mucosal damage to the stomach                   Gun shot injuries
     while ligating the short gastric vessels.
   Left basal atelectasis, sometimes with pleural effusion     Organs injured
      Due to damage or to irritation of the left                  Abdominal wall
          hemidiaphragm by a subphrenic abscess (this may           Liver
          be accompanied by persistent hiccough)                    Spleen
   Pancreatitis
                                                                    Bowel and stomach
   Damage to the tail of the pancreas during mobilization
                                                                    Mesentery
     of the splenic pedicle  pancreatic fistula  left             Kidneys and urinary bladder
     pleural effusion, peritoneal effusion or abdominal wall
                                                                    Great vessels
     dehiscence
   Gastric fistula due to damage of the greater curvature      Clinical presentation
     of the stomach when ligating the short gastric vessels.
   Paralytic ileus                                             It depends upon the severity of the injury and the organ
                                                                 involved. The types of presentations are –
Post splenectomy sequelae                                         Immediate fatality due to rupture of great vessels or
   1) Haematology                                                   avulsion of the pedicles of the organs like spleen
      Rise in the white cell and platelet count                 Features of haemoperitoneum
          There may be a risk of thrombosis if the                   Features of shock
              platelet count rises above 1000 X 109 /L and             Tenderness, guarding and distension are present
              it is essential to anticoagulate prohylactically            depending upon the amount of bleeding or
   2) Septicaemia                                                       intestinal contents leak into the peritoneal cavity
      It is due to absence of the following functions of        Delayed features of haemoperitoneum and shock
         spleen                                                   Features of peritonitis due to perforation of the bowel
          Phagocytosis of bacteria, particularly
              encapsulated bacteria.                             Investigations
          Reduced antibody production (deficient in               Urine for microscopy
              tuftsin, IgM and properdin levels)
                                                                    Plain X ray abdomen:
      Causative bacteria: streptococcus pneumoniae,
                                                                       Pneumo peritoneum in perforations of the bowels
         pneumococcus, Neisseria meningitides,
                                                                       Fracture of lower ribs in liver and splenic injuries
         haemophilus influenza, and E.coli and Babesia
         microti.                                                      Fracture of transverse process in renal injuries
      Clinical features: opportunistic infections of              Serum amylase
         lungs, brain, malarial fever (OPSI)                        Ultra sound scan of abdomen
                                                                    Diagnostic peritoneal lavage
Opportunistic post-splenectomy infection                            C.T. scan
(OPSI)                                                                 Useful to evaluate injuries of liver, spleen,
   Preventive vaccination against pneumococcus, H.                      duodenum, pancreas, kidneys and major vessels
     influenza, meningococcus                                       Angiography in suspected vascular injuries
   Patients living in malaria endemic areas should                Laparoscopy
     receive antimalarial prophylaxis.
   Antibiotics (amoxicillin) for 2 years in adults and upto
                                                                 Treatment
     the age of 15 years in children.                            Resuscitation
   To prescribe antibiotics for all infections.
                                                                     ABCD
TRAUMA TO ABDOMEN                                                   Naso gastric aspirations
                                                                    IV fluids/ blood transfusion
Causes                                                              Antibiotics
                                                                    Monitoring vital data
   Blunt abdominal trauma
      Automobile accidents                                     Laparotomy
      Human or animal assaults                                 Indications
      Fall from heights
                                                                    Evidence of injury to any intra abdominal organ
   Blunt trauma to lower chest
   Penetrating injuries                                        Procedure
Yogi Ram’s lectures on Surgery
                                                                                                         The spleen 59

   Auto transfusion of blood collected in the peritoneal          Spontaneous bleeding from mucous membrane (e.g.
     cavity, if there is no injury to bowel or if there is no         epistaxis and menorrhagia in women), and prolonged
     bile or intestinal leak into the peritoneal cavity               bleeding of minor wounds.
   The injured organ is dealt with by appropriate                 Urinary and gastrointestinal haemorrhage and
     measures                                                         haemarthrosis (rare)
                                                                    Intracranial haemorrhage is also rare, but is the most
IDIOPATHIC THROMBOCYTOPENIC                                           frequent cause of death.
PURPURA                                                             Tourniquet test is positive.
                                                                    The spleen is palpable in only 25% of cases, and gross
Purpura = prophyra (Greek) = purple.
                                                                      splenic enlargement suggests that the diagnosis is not
Definition                                                            ITP.

Purpura is defined as local haemorrhage into the skin.
                                                                 Differential diagnosis of purpuric rash
                                                                    Peticheal rash
Causes of Purpura                                                   Scurvy
  1) Increased capillary fragility, e.g., in steroid-induced   Investigations
    or Henoch -Schonlein purpura.                                   BT prolonged, but the CT and PTT are normal.
 2) Defective platelets (thrombocytopathies), e.g., after         The platelet count: reduced (usually less than 60 X 109
    taking aspirin, which inhibits thromboxane and                    /litre).
    prostaglandin, reducing the adhesiveness of platelets.          Bone marrow biopsy: increased number of
 3) Reduced number of normal platelets                              megakaryocytes
    (thrombocytopenia).
     Decreased production by marrow megakaryocytes             Treatment
     Marrow suppression by cytotoxic chemotherapy              In children
     Aplastic anaemia.                                            As the disease regresses spontaneously after first
 4) Increased platelet consumption                                  attack, medical treatment is advised
     Disseminated intravascular coagulation                       Steroids and azathioprine are given for short periods
     Large haemangioma in which platelets adhere to               Splenectomy for severe relapsed cases and for girls
         the abnormal endothelium                                     approaching menarche
 5) Increased platelet destruction by the spleen.
     Autoimmune disease (e.g. systemic lupus                   In adults,
         erythematosus)                                             The initial attack is less severe than in children, but
     Drug reactions, e.g., quinine                                  the disease relapses and becomes more severe.
     Infections (e.g. mononucleosis).                             Medical treatment
     Increased splenic sequestration                                 Steroids, blood or platelet transfusions to control
 6) ITP (the platelet destruction may not be associated                  thrombocytopaenia
    with any other condition.)                                      Surgery
(Splenectomy may sometimes be helpful in purpura                       Splenectomy is indicated where the ITP has
associated with splenic destruction or sequestration. It is                persisted for more than 6 – 9 months.
most useful in the management of ITP).                           Prognosis
Idiopathic Thrombocytopenic Purpura                                 About 15% does not derive benefit from the
                                                                      splenectomy.
Aetiology                                                           Usually, a response to steroids predicts a good
   Development of autoantibodies to platelets (the                  response to splenectomy.
     normal blood platelet count is 250 X 109 to 400 X 109
     /litre).                                                    THE HAEMOLYTIC ANAEMIA
   The children born to mothers with ITP may have
     temporary maternal antibody induced
                                                                 Introduction
     thrombocytopenia after birth.                               The haemolytic anaemias amenable to splenectomy are –
Clinical Features                                                 Hereditary spherocytosis.
                                                                  Acquired autoimmune haemolytic anaemia.
   Purpuric patches (ecchymoses) in the skin and mucous
     membrane                                                     Thalassaemia
      More prominent in dependent areas because of a            Hereditary elliptocytosis.
         gravity aided intravascular pressure.                    Pyruvate kinase deficiency.


                                                                                          Yogi Ram’s lectures on Surgery
60 The spleen

Hereditary spherocytosis                                        pallor, and jaundice
                                                                Investigations
Pathology
                                                                   Blood film examination
Cause                                                              The fragility test:
   Congenital defect in the red cell membrane, with                 Increased fragility of erythrocyte (normal: R.B.C
     increased permeability to sodium.                                   haemolyse in 0.47% saline solution. In this
   Genetic: Mendelian autosomal dominant.                              condition haemolysis occurs in 0.6% or in even
Incidence                                                                stronger solutions)
                                                                   The reticulocyte count: increased
Males and females are equally affected.                            Faecal stercobilinogen: increased
Pathogenesis                                                       Radioactive chromium: shows the degree of red cell
   Increase in permeability of the red cell membrane to            sequestration by the spleen.
     sodium  osmotic pressure in the red cell rises              Ultra sound Scan:
     R.B.C swells and becomes more spherical                          To estimate the size of spleen and to see for any
   To keep the sodium out, the sodium pump has to work                 gallstones.
     harder causing increase in the energy and the oxygen       Treatment
     requirements of the R.B.C  Weakening of the cell             Splenectomy.
     membrane  fragility of cell membrane.                           In juvenile cases, it is done at 7 years
   The energy and oxygen requirements are particularly                  Surgery at earlier age may make the child
     difficult to satisfy in the spleen, where there is                      vulnerable to infections
     deficiency of both glucose and oxygen  destruction                  Surgery at later age may cause gall stones
     of large number of red cells in the spleen
   (Splenectomy does not cure the congenital defect in        Acquired Autoimmune Haemolytic
     the red cell membrane, but it lessens the anaemia due      Anaemia
     to the removal of the spleen, the grave yard of the
     R.B.C, and makes the red cell survival time normal)        Pathology
   Increased red cell destruction  Increased levels of       Because of autoimmune reaction to red cell membrane, red
     unconjugated bilirubin (Acholuric jaundice)  Liver        cell survival is reduced
     conjugates and excretes the excess bilirubin in the bile
     (Hence, the levels of serum bilirubin is low inspite of    Aetiology
     increased production of bilirubin)  Formation of             Idiopathic
     pigment stones in the gall bladder                            Drug reaction (e.g. to -methyldopa),
Clinical features                                                  Associated with SLE
  Anaemia                                                     Clinical features
  Jaundice                                                       Age: 50 years
     Mild and may not appear until adolescence or                Sex: in women.
         even adult life.                                          Splenomegaly
     Sometimes the patient is born jaundiced                     Pigment gallstones (20% of cases)
 Biliary colic due to pigment stones in common bile
                                                                Investigations
    duct
Every child with gallstones should be investigated for             Blood
heredity spherocytosis and family history should be                   Anaemia with spherocytosis
enquired                                                              Coomb’s test is usually positive.
 Spleen is enlarged.                                          Treatment
 Sometimes the liver is also palpable.
                                                                   Usually, the disease has an acute, self-limiting course,
 Chronic leg ulcers
                                                                     and no treatment is necessary
Haemolytic crisis                                                  Corticosteroids
Sometimes, severe crisis of red blood cell destruction,         Indications for surgery (splenectomy)
precipitated by acute infection, leading to death occurs in
infancy or childhood.                                              Failure of steroids or where steroids are
During a crisis, an erythrocyte count may fall from 4.5              contraindicated
millions to 1.5 millions in less than a week.
Such crises are characterized by the onset of pyrexia,
                                                                TROPICAL SPLENOMEGALY

Yogi Ram’s lectures on Surgery
                                                                                                  The spleen 61




Causes                                                       A) Mild (tip of spleen is palpable)
Massive enlargement of the spleen occurs frequently in the      Acute infections
tropics due to                                                     Viral hepatitis
 Malaria (especially in children),                               Glandular fever
 Kalaazar and                                                    Typhoid
 Schistosomiasis                                              Chronic infections
 ? Abnormal immune response to malaria or unusual                Bacterial endocarditis
     species of plasmodia.                                         Brucellosis
 Malnutrition                                                    Tuberculosis
                                                                Haematological
Pathology
                                                                   Megaloblastic and iron deficiency anaemia
   The spleen is grossly enlarged (2000 – 4000G)                 Polycythaemia
   The enlarged spleen causes sequestration of R.B.C and         Myeloma
     platelets                                                     Idiopathic thrombocytopenic purpura
                                                                Collagen diseases
Treatment                                                          Rheumatoid arthritis
Splenectomy                                                        Lupus erythematosus
                                                                Infiltration
Indications                                                        Amyloidosis
   Anaemia                                                       Sarcoidosis
   Pain or discomfort by the weight of an enormous            Cysts
     spleen.
                                                             B) Moderate (upto umbilicus)
Post splenectomy precautions
   Antimalarial chemotherapy (e.g. proguanil) for life.       Portal hypertension
                                                                Haemolytic anaemia
HYPERSPLENISM DUE TO PORTAL                                     Leukaemia
HYPERTENSION                                                    Lymphoma
                                                                Cyst
   Splenomegaly accompanies portal hypertension.
   Associated with thrombocytopenia (due to splenic        C) Massive (upto right iliac fossa)
     sequestration of platelets) and granulocytopenia.
                                                                Myeloid leukaemia
   These are permanently relieved when splenectomy
                                                                Myelofibrosis
     accompanies the relief of portal hypertension.
                                                                Gaucher’s disease
   Shunt surgery alone does not have the same effect.
                                                                Tropical splenomegaly
CAUSES OF SPLENOMEGALY                                             Malaria
                                                                   Kalaazar
 (Spleen should enlarge 2 ½ – 3 times its normal size for       Hydatid cyst
becoming palpable clinically)




                                                                                    Yogi Ram’s lectures on Surgery
62 Preoperative preparation and anaesthesia



Chapter 7

 PREOPERATIVE PREPARATION AND
         ANAESTHESIA
INTRODUCTION                                                           alternate treatments for the disease should be
                                                                       explained to the patient and the close attendants
A surgical patient during surgery undergoes –                          and a written consent has to be taken
 Metabolic response to trauma                                      If any part of the body has to be removed, a
 Effects of anaesthesia on metabolism, cardio-vascular               consent to that effect must also be taken in
     and central nervous systems                                       writing
 Surgical trauma with resultant blood, fluid and
     electrolyte loss; tissue access to microbes              PREPARATION OF PATIENT’S SKIN
Hence, every patient undergoing surgery should have           (OPERATING AREA)
preoperative evaluation for fitness to withstand these
challenges, and should have monitoring of the vital           The area of operation requires much greater attention than
systems during surgery and post-operative period.             the hands of the surgical team. It is of no use to apply
                                                              antimicrobials to a dirty and unclean area, however strong
PRE OPERATIVE EXAMINATION                                     and broad-spectrum they may be.
                                                              In the ward
To assess the fitness of the patient for anaesthesia and
surgery                                                        Shaving
 Haemodynamic system: blood pressure, pulse rate,            Cleansing with detergent
    HB%                                                        Painting with antiseptics
 Cardio-respiratory systems                                 In the operation theatre
     Clinical examination
     In selected cases, X ray chest, ECG,                    Painting with antiseptics.
        echocardiogram and TMT                                Procedure in the ward
 Renal system
     Blood urea or creatinine                               1) Shaving
 Bleeding diathesis                                         Shaving of the proposed operation site and the adjacent
     BT, CT, PTT                                            area is not only aesthetic but also is helpful by not
 Metabolic system: diabetes mellitus                        obscuring the operating field, especially, the scalp, pubic
 Neurological diseases, jaundice, sepsis                    and perineal areas. However, it causes minor cuts on the
                                                              skin that permits bacterial growth. Shaving the operating
HIV and HBsAg                                                 area one day before surgery significantly increases the risk
   Universal precautions should be taken in every case to   of wound infection. Hence, shaving should be performed
     prevent cross infection to the medical personnel         as close to the time of operation as possible and the
                                                              interval between the shaving and the operation should not
PREPARATION OF THE PATIENT                                    exceed six hours.

   Nothing by mouth for 8 hours before surgery
                                                              2) Cleansing with detergent
   Bowel evacuation                                         After shaving, the area to be operated upon should be
      By a mild laxative night before the surgery or by     cleansed thoroughly with detergent to free the soil, dirt and
         soap and water enema                                 the microbial flora. Special attention has to be paid to
   Sedation                                                 creases and crevices like umbilicus, groin, axilla, etc. A
                                                              special care should be taken for ostomy openings and
      Nitrazepam or diazepam or phenobarbitone the
                                                              around them. If exudative or infective lesions are present
         night before surgery to allay anxiety and
                                                              in the area or adjacent area to operation, the surgery (if
         apprehension
                                                              elective) has to be postponed. After cleaning, the area
   Consent
                                                              should be dried with a clean and dry towel. (Moist areas
      The procedure to be done, its sequelae and            attract bacterial colonisation.)
Yogi Ram’s lectures on Surgery
                                                                     Preoperative preparation and anaesthesia 63

3) Anti-microbial painting                                      not be reused to paint the central area. The preparation
                                                                should last for 3 – 5 minutes for the optimum action of
Any of the antimicrobials may be used to paint the area,
                                                                antimicrobials.
after cleaning with the detergent. The area is covered with
                                                                If the area is unclean or soiled, or surgery is planned for
a sterile or clean towel.
                                                                artificial implants, two or three sponges may be used.
Properties of few routinely used anti-                          Each time the sponge is discarded and a new sponge
microbial agents*                                               impregnated with antiseptic is held with the forceps. While
   A) Alcohols (ethyl, n-propyl, and isopropyl): they are       the new sponge is handed over to the tips of the sponge-
   effective in concentrations of 50% – 70%. Drying for         holding forceps, sufficient precaution should be taken not
   ten seconds after application increases their                to touch the tips of the forceps with the gloved hand.
   effectiveness. They are highly effective and act rapidly     Finally, 60 – 70% alcohol is painted over the area and
   with broad-spectrum activity except against spores. The      allowed to dry for 10 seconds to have complete or total
   organic matter can inactivate them, and alcohol can          bactericidal action of alcohol.
   irritate the mucous membranes and cause dryness of the       A thorough cleansing of the skin, free from dirt, grease
   skin.                                                        and soil is an essential pre-requisite in skin preparation.
   B) Chlorhexidine gluconate (0.25 – 0.5%): it has             Antimicrobial application is only a supplement and not a
   potent broad-spectrum activity except against myco-          substitute.
   bacterium tuberculosis. It should be swabbed for at
                                                                ANAESTHESIA
   least two minutes and should be repeated second time
   for two minutes for efficient action. It has marked and      Pre medication
   persistent action for 4 – 6 hours. It should be kept out
   of eyes, meninges and mucous membranes of some              These drugs are given before any form of anaesthesia –
   organs like middle ear and oral cavity. It is also used as    To counter the harmful effects of anaesthetic drugs
   0.5% solution in 70% alcohol.                                 To induce sleep and reduce the dose of anaesthetic
   C) Iodine/iodophors (povidone iodine): they are highly           agents
   effective and possess broad-spectrum activity.               Drugs
   Iodophors require contact time of two minutes to
   release free iodine. They can be used on mucous                 Atropine: it is given before general anaesthesia
   membranes. They have minimal residual activity and                 To dry the secretions and to prevent the
   their effectiveness is reduced by organic matter,                     bradycardia and hypotension
   irritates skin when pooled on it and causes allergy in a           Dose: 0.01 mg/Kg body wt
   few people.                                                     Hypnotics: morphine, pethidine, pentozocaine,
(*Nomenclature of antimicrobial techniques:                          diazepam
Asepsis: prevention of entry of microorganisms into the               To allay the fear and anxiety of surgery
body.
Antisepsis: prevention of infection by killing/inhibiting the   Types of anaesthesia
microbes on skin and other body tissues                            General
Disinfection: eliminating most but not all disease causing         Regional
microorganisms from inanimate objects.                                Spinal
Sterilisation: eliminating all disease causing micro-
                                                                      Local
organisms including spores from inanimate objects)
Procedure in the operation theatre                              GENERAL ANAESTHESIA – DRUGS
                                                                 The drugs used to administer general anaesthesia are –
Preparation of the site of operation                             Basal narcotics
The skin well beyond the site of operation (a minimum of         Muscle relaxants
20 centimetres around the proposed area of operation) has        Inhalational agents
to be prepared. A sterile sponge held in long sterile sponge     Gases
holding forceps is taken. It is wrung in antiseptic lotion of
choice and the antimicrobial lotion is applied to the           Basal narcosis or induction
proposed area. It is worked from the area of proposed
incision outwards in concentric circles. The crevices, folds    These are rapidly acting drugs to produce anaesthetic state
and unclean areas should be painted to the last. Open           consisting of profound analgesia, normal pharyngo-
wounds and stomata should also be attended to the last.         laryngeal reflexes and sedation with normal muscle tone
The sponge used to ‘prepare’ the outer unclean area should      Drugs
                                                                   2.5% thiopentone sodium intravenously (10 – 20 ml)


                                                                                           Yogi Ram’s Lectures on Surgery
64 Preoperative preparation and anaesthesia

   Ketamine (2 mg/Kg IV or 10 mg/Kg IM)                       The steps of general anaesthesia are –
   Propofol                                                    Premedication: hypnotics and atropine is given
                                                                 Induction with thiopentone: intravenous
Muscle relaxants                                                    administration of thiopentone (an ultra short acting
                                                                    barbiturates induces sleep
Uses                                                             Scuccynyl choline is given, once the patient gets into
   Complete relaxation of muscles aids surgery,                   sleep to paralyse the vocal cords
     especially abdominal, and chest surgery                     Endotracheal intubation: after giving succynyl
   Gives control over the respiratory system                      choline, the patient gets twitchings followed by
   Hence, controlled respiratory assistance should be             complete and profound paralysis of all skeletal
     provided during their administration                           muscles. Then, endotracheal intubation is done
Types of muscle relaxants                                        Maintenance and monitoring: the patients is
                                                                    maintained in general anaesthetic state with the
Two types –
                                                                    following drugs and gases as long as surgery takes
 Depolarising and                                                 place.
 Non-depolarising                                                  General anaesthetic drugs
Depolarising relaxants - E.g.: suxamethonium                               Volatile: ether or halothane with nitrous
(50 – 100 mg) /IV                                                              oxide gas and with Oxygen
They act like acetylcholine with persistent action causing           Long acting muscle relaxants are given and the
spread of depolarisation to the adjacent muscle making it                 patient is ventilated
unresponsive to stimulus. These drugs are hydrolysed by          Reversal of anaesthesia is done when surgery is
serum cholinesterase. They produce twitchings followed              completed by discontinuing the nitrous oxide and
by profound muscle relaxation for 4 – 5 minutes.                    halothane and patient is ventilated with 100% oxygen
Congenital absence or impaired production of                        till the muscle relaxant effect wanes. Then,
cholinesterase due to liver disease can cause prolonged             neostigmine and atropine are given.
muscle relaxation till the cholinesterase is infused by fresh    Extubation is done after complete recovery of the
blood transfusion.                                                  reflexes, especially gag reflex
 Use: for endotracheal intubation and for ultra short          Postop analgesia is administered with morphine,
    procedures                                                      pethidine, pentozocaine, or tramadol.
Non-depolarising relaxants                                      Complications
These drugs prevent adsorption of acetylcholine to the             Shock
cholinergic receptors and prevent depolarisation in the
                                                                   Respiratory failure
endplate, which causes muscular tone and contraction.
                                                                   Cardiac failure
There are no fasiculations. They have longer duration of
action (20 – 45 minutes). Their action is reversed by           REGIONAL ANAESTHESIA
neostigmine (anticholinesterase), which increases the
concentration of acetylcholine at the motor end plates.         Drugs
Drugs
   Tubocurarine chloride, gallamine, pancuronium
                                                                Lignocaine (0.5% to 1% solution)
     (pavulon)                                                     Duration of action: 1 – 2 hours
   Vecuronium, atracurium, cisatracurium (recent ones)           Max dose: 3 mg/Kg, 7 mg/Kg if mixed with
                                                                     adrenaline (1:250 000)
Inhalational agents                                                Adrenaline retards absorption and prolongs the
                                                                     anaesthetic effect
   Ether
                                                                      It should not be given for finger block, penile
   Trilene
                                                                         block and for ear lobule
   Chloroform
                                                                   Side effects: cardiac depression, drowsiness,
   Halothane, enflurane, and sevoflurane (recent ones)             convulsions and unconsciousness
Gaseous agents                                                  Bupivicaine (0.25 – 0.5% solution)
   Nitrous oxide                                                 Duration of action: 5 – 8 hours
   Cyclopropane                                                  Max dose: 2 mg/Kg
                                                                Ropivacaine
PROCEDURE OF GENERAL
ANAESTHESIA                                                     SPINAL ANAESTHESIA
Yogi Ram’s lectures on Surgery
                                                                    Preoperative preparation and anaesthesia 65


Methods                                                           Sensory block above T6

   Intrathecal (sub arachnoid) anaesthesia: injection of     Extra dural anaesthesia
     local anaesthetic, e.g., lignocaine or bupivicaine into
     subarachnoid space                                        Method
   Epidural (extra dural) anaesthesia: injection of local    Injection of 10 – 15 ml of lignocaine (1-2%) or
     anaesthetic, e.g., lignocaine or bupivicaine into         bupivacaine (0.5%) into epidural space
     epidural space                                            Advantages
Sub-arachnoid anaesthesia                                         Less danger of meningitis and neurological sequelae
                                                                  Absence of postoperative headache
Procedure                                                         Prolonged postoperative analgesia
Hyperbaric local anaesthetic agent is injected below the          Repeated injections can be made into the space by
conus medullaris (below L1) into the subarachnoid space             inserting a cannula in to the space. E.g., obstetric
by lumbar puncture                                                  analgesia, following chest trauma, pain relief in acute
The lumbar puncture needle is passed through                        pancreatitis, chronic pain due to cancer
supraspinous, interspinous ligaments, and ligamentum              The incidence of bradycardia and circulatory collapse
flavum and dura matter                                              is much lower than spinal anaesthesia due to slower
Types                                                               onset of sympathetic blockade allowing more time for
                                                                    the compensatory changes to develop above the level
   Low spinal (L4/5 space in sitting posture)                     of blockade
      Block of S2 – S5
   Mid spinal (L3/4 space with 50 Trendelenburg’s tilt)      Disadvantages
      Block of T7 – L4                                          Danger of sub arachnoid injection with total spinal
   High spinal (L2/3 space with 50 Trendelenburg’s tilt)          paralysis
      Block of T3 – L5
                                                               LOCAL ANAESTHESIA
Indications
Lower abdominal surgeries, e.g., hernia, hydrocele, anal       Methods
surgery, hysterectomy and other pelvic procedures
                                                                  Surface anaesthesia, e.g., mucosal anaesthesia of
Complications                                                       urethra, eye, throat etc
   Hypotension due to paresis of spinal sympathetic out         Infiltration anaesthesia
     flow                                                         Field block, e.g., hernia block, breast block,
      If the block is above T10 level, the fall of blood        Nerve block, e.g., brachial plexus, cervical plexus
         pressure is profound and dangerous (hence, spinal          block, intercostal block, ring block
         block is made between T10 – L4 segments)
      It is usually associated with bradycardia              SUTURE MATERIALS
      Prevention: preoperative fluid loading with one        Types of suture materials
         litre of Ringer's lactate solution
      Treatment: parenteral injection of vasopressor         Sutures are broadly classified into two groups 
         agents, e.g. mephenteramine                           absorbable and non-absorbable. Each is again classified
   Respiratory depression                                    into natural and synthetic.
      Due to hypoxia of respiratory centre due to severe      Absorbable
         hypotension                                                 Natural
      Due to paralysis of respiratory muscles                          Catgut (surgical gut)
   Nausea                                                                   Plain
   Post operative headache, retention of urine,
                                                                              Chromic
     meningitis, abducent palsy
                                                                     Synthetic
Risk factors for spinal anaesthesia                                      Polyglycolic acid, polyglecaprone 25
Presence of two or more following factors indicate high                  Polyglactin 910
risk –                                                                   Polydioxanone (PDS)
 Resting pulse rate less than 60 per minute
                                                                Non- absorbable
 Age more than 50 years
                                                                     Natural
 ECG: prolonged PR interval
 Use of beta blockers                                                  Cotton


                                                                                          Yogi Ram’s Lectures on Surgery
66 Preoperative preparation and anaesthesia

          Linen                                                 tissues where hitherto non-absorbable suture material was
          Silk                                                  indicated.
                                                                  These sutures are less pliable and needs a special knotting
     Synthetic
                                                                  technique. Two throws in the first hitch and one in the
        Polyamide (nylon)                                       second and third (surgeon’s knot). These are available as
        Polypropylene                                           braided and monofilament strands.
        Polyester
        Stainless steel                                         Non-absorbable sutures
Absorbable sutures                                                Natural non-absorbable sutures
                                                                  Silk: it is derived from cocoon of silkworm. As it is a
Natural absorbable sutures                                        protein, it produces intense tissue reaction. Unlike catgut,
Surgical Gut (catgut)                                             it is not absorbed and produces granulomata or sinus till it
                                                                  is extruded, especially, when used nearer to the skin.
It is derived from the sub mucosa of a sheep’s intestine
                                                                  Encapsulation with fibrous capsule usually occurs in 14 –
(not from the cat’s gut). These threads resemble the strings
                                                                  21 days and is delayed if infection supervenes. It has high
of some musical instruments like Kit (a small fiddle used
                                                                  tensile strength for two years. It has excellent handling
by dancers). Hence they were called as ‘Kitguts’ and later
                                                                  properties and is considered as a benchmark for sutures. It
as catguts (young cats are called kitten).
                                                                  can be tied easily and securely.
As catgut is a pure collagen, which is a foreign protein, it
                                                                  Linen: it is made from a plant called flax (Linum
produces intense tissue reaction. Catgut is of two types         usitatissimum), cultivated for its textile fibre. It has
plain catgut and chromic catgut.                                  properties similar to silk. It gains strength when becomes
 Plain Catgut: it loses its complete tensile strength in        wet. So, it is extensively used for ligating pedicles.
      fifteen days and absorbed in forty to sixty days            Cotton: it is derived from the hair of cotton-seed. It is
      depending upon its size. It elicits an early and intense    weaker than linen and handling is inferior to silk.
      tissue reaction. Because of the early loss of its tensile   Because of their tissue reaction, these natural sutures are
      strength when the support of the wound is crucial and       replaced by synthetic non-absorbable sutures.
      due to its intense tissue reaction, it is not used
      routinely.                                                  Synthetic non-absorbable sutures
 Chromic Catgut: it is manufactured by coating the              Polyesters (Terylene, Dacron): they have high tensile
      plain catgut with salts of chromic acid. (Lord Joseph       strength and retain indefinitely with low tissue reactivity.
      Lister borrowed the idea of tanning of leather by           They have a tendency to cut through the tissues and so
      chromic acid, to make chromic catgut). Because of           they are coated with PTFE, Teflon, or Polybutylate. Their
      coating with chromic salts, the tissue reaction             handling properties are excellent.
      becomes slow and less intensive and so absorption is        Polyamide (Nylon): it has low tissue reaction and loses
      delayed. Chromic catgut loses all its tensile strength      25% of its tensile strength after two years. It has a
      in thirty days and disappears in sixty to one hundred       property called “memory” (a tendency to return to the
      and twenty days, depending upon its size and the            shape set during manufacturing process or packaging). So,
      tissues where it is used. These sutures are absorbed by     it tries to untie the knot spontaneously. Hence, it needs
      enzymatic digestion from enzymes liberated from             three or four throws in the knot. Handling is not good as
      cellular response. They are monofilament and can be         the strand is stiff.
      handled easily with a secure knot at second throw.          Polypropylene: it has extremely low tissue reactivity and
Catgut is used mainly for subcutaneous sutures, ligating          retains its tensile strength indefinitely. Handling is good
small vessels and intestinal anastomosis. Because of the          and knots well as it deforms on knotting and beds down on
tissue reaction and unpredictable absorption, synthetic           itself. It also needs three or four throws for secure
absorbable sutures are fast replacing catgut sutures.             knotting. It can stretch to 30% without loss of tensile
                                                                  strength. Hence it is very useful where some swelling of
Synthetic absorbable sutures                                      tissues is expected in the postoperative period, as the
 Polyglycolic acid (Dexon), polyglactin 910 (Vicryl),             swollen tissues in the suture are not strangulated because
polyglecaprone 25 and polydiaxonone (PDS) are the                 of its capability to stretch.
commonly used synthetic absorbable sutures. They evoke            Stainless steel: it has excellent strength and low tissue
little tissue reaction and are absorbed by hydrolysis in the      reaction (inert). It has poor handling characters. It kinks
presence of the tissue fluids.                                    on knotting, which makes it weak, and hence, proper
Polyglycolic acid and polyglactin 910 lose their tensile          knotting technique has to be used. Barbs on the ends of
strength in 30 days and absorbed in 90 days.                      the sutures can traumatise the tissues
Polydiaxonone takes 50 days to lose its tensile strength and       Synthetic non-absorbable suture materials also need
180 days to get absorbed. Because of longer tensile                     the same knotting technique as that of the synthetic
strength retention, it is used safely in some slow healing
Yogi Ram’s lectures on Surgery
                                                                       Preoperative preparation and anaesthesia 67




absorbable sutures, i.e., surgeon’s knot.

                                           Loss of tensile    Absorptio    Absorption    Tissue
                                             strength            n          mode *      reaction
                                       50%        100% loss    (Days)
                                       loss       (days)
                                       (days)
                      Plain catgut     3          15          60-120      Enzyme        High
                                                                          digestion

                       Chromic         6-10       30          60-120      Enzyme        Mild to
                        catgut                                            digestion     moderate

                      Polyglycolic     17         30          90          Hydrolysis    Low
                       acid and
                      polyglactin
                         PDS           35         50          180         Hydrolysis    Low

                     Silk, linen &     ---        >2 years    Nil         ---           High
                        cotton


                     Polyester &       ---        Indefinit   Nil         ---           Low
                     polypropylen                 e
                          e
                        Nylon          ---        25%         Nil         ---           Low
                     (polyamide)                  loss
                                                  after 2
                                                  years
                     Stainless steel   ---        Indefinit   Nil         ---           Low
                                                  e
                    (*Enzyme digestion  more tissue reaction; hydrolysis  less tissue reaction)




                                                                                          Yogi Ram’s Lectures on Surgery
68 Surgical procedures


Chapter 8

                    SURGICAL PROCEDURES
Describe the following for every surgical procedure      FNAC
 Indications                                           Trucut biopsy
 Anaesthesia                                           Endoscopic biopsy
 Position of the patient                               Incisional biopsy
 Incision and access                                      Done for inoperable tumours to establish the
 Qualities of good incision                                   diagnosis
     Accessibility                                     Excisional biopsy
     Extensibility                                     Removal of organ and biopsy (e.g., orchidectomy for
     Safety                                              suspected testicular mass and lymph node for
     Cosmetic                                            lymphoma)
 Method of surgical procedure                          Sentinel node biopsy
 Closure                                               Laparoscopy and laparoscopic ultra sound scan
 Complications                                         Frozen section biopsy

POSTURES                                              VENOUS CUTDOWN (VENESECTION)
   Supine                                           Site of election
   Prone
   Lithotomy                                           In adults, anticubital, cephalic in the arm; long
                                                           saphenous vein anterior to med malleolus
   Lloyd-Davis
                                                         In children, long saphenous vein, external jugular vein
   Lateral
                                                           in neck
   Trendelenburg’s
   Ante Trendelenburg’s                             Procedure
OPERATIONS OF INTEREST                                   A tourniquet is applied proximal to the vein of
                                                           election
   Abdominal incisions                                 Incise the skin, dissect the vein and pass two ligatures
   Gastrostomy                                           around it
   Gastrojejunostomy                                   Tie the distal ligature and cut the vein
   Cholecystectomy                                     Through the venotomy pass a venous catheter and tie
   Splenectomy                                           the proximal ligature over the vein and the catheter
   Colostomy                                           Suture the skin and the catheter is brought out through
   Appendicectomy                                        a separate stab incision
   Inguinal Hernia
   Femoral hernia                                   GASTROSTOMY
   Haemorrhoidectomy
   Surgical approaches to kidney                    Indications
   Supra pubic cystostomy                              Drainage of stomach
   Hydrocele                                           For feeding
   Vasectomy
   Circumcision                                     Types
   Laparoscopy
                                                         Open method
                                                            Stamm’s
            BASIC SURGICAL                                  Witzel’s
             PROCEDURES                                  PEG (per cutaneous endoscopic gastrostomy)
                                                      Stamm’s gastrostomy
PROCEDURES FOR DIAGNOSIS OF
CANCER                                                Incision
Yogi Ram’s lectures on Surgery
                                                                                            Surgical procedures 69


   Left paramedian muscle splitting                         THORACOTOMY
Procedure
                                                              Anaesthesia
   Stoma is selected on the anterior wall of body of the
     stomach between the curvatures                              One lung anaesthesia by Carrel’s tube
   Three tiers of purse string sutures are applied around
     the opening in the stomach wall                          Incision
   The tube is passed through the opening and the purse        Intercostal space in 6th, 7th or 8th space or
     string sutures are tied while pushing the tube inside       Over the rib or through the rib bed after resection of
     inverting the stomach wall around the tube                    the rib or
   The stomach is anchored to the parietal peritoneum          Sternotomy
     around the stoma
                                                              Procedure
Witzel’s gastrostomy
                                                                 The pleural cavity is opened
   The tube is laid in a seromuscular tunnel on the wall
                                                                 Ribs are widely held apart by a mechanical rib
     of the stomach after inserting in the opening of the
                                                                   spreader
     stomach
                                                                 The lung is mobilised by dividing the pulmonary
JEJUNOSTOMY                                                        ligament and retracted forwards
                                                                 Closure is done by suturing the intercostal muscles in
Indications                                                        two layers after leaving a chest drain and connecting it
                                                                   to a under water seal
   Feeding, e.g., following major gastric resections,
     oesophago gastrectomy, inoperable cases of
     carcinoma stomach
Site
   15 – 25 centimetres below DJ junction
Procedure
   Stamm’s or Witzel’s method

VASECTOMY
Indications
   Family welfare purpose
   Prophylactic before Freyer’s prostatectomy to prevent
     epididymo-orchitis
Procedure
   Cord is held between thumb in front and index and
     middle fingers behind at the root of the scrotum
   The vas is felt and held between the fingers
   Local anaesthetic is injected, incision made over the
     skin, fasciae of the cord, the vas isolated and a 2
     centimetres length of the vas removed between silk
     ligatures
   Wound closed in layers
Complications
   Haematoma
   Wound infection
   Sperm granuloma
   Spontaneous recanalisation

                                                                                          Yogi Ram’s Lectures on Surgery
Chapter 9
                   DIAGNOSTIC RADIOLOGY
BASIC PRINCIPLES                                                   Is it taken in erect or supine position?

Conventional radiology is the basic method of diagnostic        Plain/contrast
radiology. In this method, the two dimensional images of
                                                                   The label on the X ray film has to be studied to know
the body are studied on a photographic film. X rays are
                                                                     whether it is a plain or contrast X ray because radio-
passed through the human body and the images are caught
                                                                     opaque densities are demonstrated on plain X ray and
on a film loaded in a film cassette, which is placed on the
                                                                     not on contrast X ray ( E.g., stag-horn calculus may be
other side of the body, i.e., opposite to the X ray beam
                                                                     mistaken for pelvi-calyceal system on IVP)
generator. When X rays fall on the film, a photochemical
reaction takes place emitting light rays, which expose the      View of the X ray
photographic film with in the cassette.
                                                                   The X rays are passed from a X ray generator through
Interpreting the images on X ray film                                one side of the patient’s body and an X ray film is
                                                                     kept on the opposite side. If the X rays are passed
   When X rays pass through the tissues, they are
                                                                     from anterior to posterior side, it is called an AP view
     attenuated by the body tissues by absorption and
                                                                     (antero-posterior view)
     scatter. Basing on the amount of attenuation, X ray
     images demonstrate seven radiographic densities –             The parts of the body which are close to the x ray
                                                                     plate are visualized well, i.e, in an AP view of the
      Air
                                                                     abdomen, the posterior abdominal wall structures are
      Fat
                                                                     better visualized
      Soft tissues
                                                                      For abdominal X rays, usually, AP view is taken
      Bone
                                                                      For chest X rays, PA view is taken
      Calcified structures or objects containing calcium
                                                                      For X rays of the spine (vertebral column), AP
          (e.g., urinary calculi)
                                                                          view is taken
      Radio-contrast materials
      Metallic bodies                                         Erect/supine
   Air appears as a black shadow, as air can not attenuate
     the X rays and the full beam of X rays pass through           Fundic gas shadow helps to identify the posture, in
     causing black shdows on the film                                which posture X ray was taken
   Bone, metallic bodies and radio-contrast materials               It is horizontal in supine films
     (barium, iodine compounds) attenuate the X rays thus
     causing the white shadows on the X ray film. These
                                                                PLAIN X-RAY (STRAIGHT X-RAY)
     are called as radio dense or radio-opaque densities        ABDOMEN
   Fat and soft tissues depending upon their density and
     texture attenuate the X rays partially causing shades of
                                                                Preparation of a patient for an elective
     gray shadows                                               plain X-ray film
      The fat covers of certain organs make them                 As the gas in the bowel causes black shadows on X
          visible as shadows on X rays, like renal shadows,          ray interfering with visualization of the small radio-
          lower margin of the liver, spleen                          opaque shadows, it should be rid of the bowels.
      The muscles like psoas major cast a shadow on                Hence, laxatives/purgatives are given for 2 days prior
          plain X ray of the abdomen                                 to x-ray and the patient is advised fasting for 8-12
                                                                     hours before taking the X-ray
X-RAY ABDOMEN
When a X ray film is given to the student to read the X ray,
                                                                Extent of exposure
the following have to be studied –                                 It should extend from 9th rib to both ischial
 Is it plain or contrast X-ray ?                                   tuberosities
 What is the view of the X-ray?
      Is it A.P / P.A / lateral / oblique view                Structures to be looked for in a

Yogi Ram’s lectures on Surgery
                                                                                                 Diagnostic radiology 71

plain X ray abdomen                                            Points for identification of urinary calculi:
                                                                  In lateral view- renal stones cast shadow on vertebral
   Normal shadows                                                 body while gall stones cast shadow in front of
      Soft tissue shadows                                         vertebral body
         Psoas shadows                                          Renal stones are oval or stag-horn shaped and are
         Renal shadows (due to perinephric fat)                   present in the renal area
      Bony shadows                                              Ureteric stones lie along the line of ureter (Ureter
         Pelvis, spine, ribs                                      passes over tips of transverse process to sacro-iliac
      Gas shadows                                                 joint to ischial spine to pubic tubercle)
         Fundic shadow                                          Bladder stones are central and supra pubic in position
         Ileal shadows                                            and are usually oval or round in shape
         Colonic air shadows                                    Prostatic stones cast a shadow just below or over
   Abnormal shadows                                               symphysis pubis
      Abnormal soft tissue shadows
      Abnormal bony shadows                                  Abnormal gas shadows
      Abnormal RO densities                                     In the peritoneal cavity –
      Abnormal gas shadows                                         Pneumoperitoneum
   Absence of normal soft tissue shadows                        In the bowels –
Soft tissue shadows                                                  Air shadows
                                                                     Fluid levels
Kidney shadow:
   It extends from tip of L1 transverse process to L3/L4.    Pneumoperitoneum
     it is situated obliquely parallel to psoas major muscle      5 ml. of air is needed to cast a shadow on the X-ray
   It is due to peri nephric fat                                In a lateral decubitus film , 1 ml is sufficient to
                                                                    visualise the gas between the lateral flank line and
Absent kidney shadow                                                liver
   Lack of perinephric fat
   Perinephric abscess or haematoma
                                                               Causes
   Absent or ptosed kidney                                      1) Perforation of viscera
                                                                     Peptic ulcer
Kidney shadow parallel to spine                                      Trauma
   Horse-Shoe Kidney                                               Enteric fever
Absent psoas shadows                                                 Appendicitis
                                                                     Ulcerative colitis
   Perinephric abscess or haematoma
                                                                     Penetrating malignant ulcers
Abnormal radio opaque densities on a plain                        2) Diagnostic procedures:
X-ray                                                                Tubal insufflation test,
   Urinary stones                                                  Laparoscopy
   Gall stones                                                  3) Post laparotomy – after any abdominal surgery, air
   Calcified lesion in kidneys/adrenals                           gets trapped inside the peritoneal cavity and it takes
      Tuberculosis, degenerated or necrosed areas                 five to seven days to get absorbed and during that
         (tumours, haemangiomas), cyst walls, medullary             time, if X-ray is taken, it shows pneumoperitoneum
         sponge kidney, renal calcinosis, occasionally            4) Chilaiditi’s syndrome: interposition of transverse
         renal carcinomas                                           colon between liver and diaphragm
   Calcified lesion in lumbar/mesenteric lymph nodes         Pneumoperitoneum with a fluid level
   Pancreatic calculi                                           Subphrenic abscess
Other rare radio opaque densities on a plain X-                   Pneumoperitoneum with large collection of fluid in
ray                                                                 the peritoneal cavity
   Calcified costal cartilages                               Bowel shadows
   Calcified phleboliths                                        Normally a gas shadow is seen in the fundus of the
   Foreign bodies in alimentary tract – iron containing           stomach and one or two in the terminal ileum
     formulations, lead balls                                     Abnormal gas shadows are seen when there is
   Chip fractures of transverse processes of lumbar               accumulation of gas in the bowel as in intestinal
     vertebrae                                                      obstruction (both dynamic and adynamic)

                                                                                            Yogiram’s Lectures on Surgery
72 Diagnostic radiology

   In intestinal obstruction, bowel distends proximal to          obstruction/ atonic paralysis
     the obstruction
                                                               CONTRAST X-RAYS
Radiological diagnosis in intestinal
obstruction                                                    The commonly performed contrast X rays
   The proximal distended bowel contains gas and fluid,      are for the following –
     which cast a shadow on plain x-ray and is useful in
     making the diagnosis of obstruction and site of              Gut contrast films
     obstruction                                                     Barium swallow
   The gas filled bowel loops casts a shadow depending             Barium meal
     upon the mucosal pattern of the bowel                           Barium meal follow - through
   The fluid sequestration occur in the bowel later and is         Enteroclysis
     demonstrated by air-fluid levels on x-ray                       Barium enema
   Supine and erect films are taken                             Gall bladder
   It shows                                                        Oral cholecystography
      Gas shadows and air-fluid levels                          Bile ducts and pancreatic duct
      Radio opaque foreign bodies causing the                      ERCP, IOC, PTC.
          obstruction (e.g., gall stones, metallic FB)            Urinary
                                                                     IVP
Gas shadows                                                          Other investigations –
  Due to proximal distended bowel containing gas                        Retrograde pyelography, cystogram,
  Better seen on a supine film                                             urethrogram
  The mucosal pattern of the distended gut can be
    identified making the diagnosis of the site of             Barium swallow
    obstruction
                                                                  It is done to image the oesophagus and to study its
Jejunum:                                                            peristaltic activity
  Dilated loops are seen centrally and lie transversely.        Observe for
  No gas is seen in the colon.                                     Position of oesophagus and oesophago-gastric
  Characterized by its valvulae conniventes that                        junction in relation to diaphragm
    completely pass across the width of the bowel and are            Diameter of oesophagus
    regularly spaced giving a `concertina' effect.                         Dilated oesophagus occurs in obstructive
Ileum                                                                         lesions and achalasia (to differentiate observe
                                                                              for peristalsis)
 It is featureless (smooth borders)
                                                                     Filling defect
Colon                                                                      Its presence indicates space occupying lesion
  A distended caecum is shown as a rounded gas                              and the nature of the lesion is evaluated by
    shadow in the right iliac fossa                                           the following findings –
 Remaining colon shows haustral folds which are                              Borders of the filling defect – irregular
    spaced irregularly and the indentations are not placed                         or smooth
    opposite one another                                                            Irregular indicates malignancy
 Volvulus of sigmoid colon has distinct features with                        Its extent and shouldering
    out haustrations                                                 Number of peristalsis waves
The diameter of the distended viscus and the site of the          Commonly seen lesions are –
viscus is not diagnostic                                             Carcinoma, achalasia, oesophageal varices
Air-Fluid levels
                                                               Barium meal
   They are due to the sequestrated fluid in the proximal
     bowel                                                     It is done to image the stomach and the duodenum
   They are seen few hours after the onset of obstruction    Observe for –
   Seen on erect film                                         Curvature deformity – nitch or notch
   Physiological fluid levels                                 Filling defect
      In infants less than 2 years of age in the small        Duodenal filling
         bowel                                                  Stasis
      In adults, two inconstant fluid levels at the          Common lesions are –
         duodenal cap and in the terminal ileum
                                                                  Gastric ulcer
   More fluid levels = advanced obstruction/distal

Yogi Ram’s lectures on Surgery
                                                                                                Diagnostic radiology 73

   Duodenal ulcer                                              Barium meal follow through
   Carcinoma stomach
                                                                 It is done to image the small bowel after giving the barium
Findings in gastric ulcer:                                       to the patient by mouth. The whole small bowel upto the
   Persistent ulcer nitch on the lesser curvature with a       ileum and later upto the rectum is studied by following it
     notch on the greater curvature due to spasm of the          on fluoroscopy or by exposing the films frequently
     underlying muscle coat.                                     The lumen and peristaltic activity of the bowel is studied.
                                                                 It can not give complete information about the bowel
Findings in duodenal ulcer:                                      disease for the following reasons –
   The radiological findings vary according to the              Overlapping of the bowel loops making it difficult to
     chronicity of the ulcer.                                          examine a suspicious part
   In long standing cases, the fibrosis extends into the        Poor distension of the lumen
     muscular coat causing deformity of the duodenal cap.         Intermittent filling of the bowel
     (The normal duodenal cap is conical in shape)                Flocculation of the barium
   If pyloric stenosis develops, there will be non filling      Unpredictable transit time
     of the duodenal cap with distended stomach                   These problems can be over come by the procedure called
     containing food residue                                     enteroclysis
Findings in carcinoma stomach
                                                                 Enteroclysis
   Intraluminal irregular persistent filling defect =
     growth                                                      It is the method of imaging the small bowel by passing a
   In linitus plastica, the lumen of the stomach is very       specially designed tube through the nose into the
     much narrowed without any peristaltic activity of the       duodenum and later into the proximal jejunum. About six
     wall of the stomach                                         hundred ml of barium or 200 ml of barium with 1000 ml of
                                                                 methyl cellulose (to distend the bowel and to facilitate the
Oral cholecystography: (Graham – Cole                            advance of barium in the bowel) is given through the tube.
test)                                                            The small bowel lumen and the mucosal surface of the
                                                                 bowel are well demonstrated. CT compliments this study
   Certain radio opaque materials eg.; telepaque, osbil,       by demonstrating the structures outside the bowel
     Iopanoic acid are absorbed, when given by mouth and         Commonly seen abnormalities are –
     excreted by liver into bile, and gets concentrated in the    Filling defects
     gall bladder.                                                Strictures
Procedure:                                                        Mucosal oedema and ulcers
   On the night before X ray examination, six tablets of       Contra indications
     telepaque are given by mouth and X-ray abdomen is              Intestinal obstruction
     taken on the morning of the next day.
   Gall bladder is opacified and stones may be seen as         Barium enema
     filling defects.
   A fatty meal is given and 45mts later, another              It is done by administering the barium as enema into the
     radiograph is taken to assess the contractibility of gall   rectum by a rectal tube
     bladder. There is reduction by 50% in normal cases.          Observe for
                                                                        Complete filling and emptying of the bowel
Findings                                                                Filling defects (apple core deformity) and their
   In chronic cholecystitis, the following are observed                  nature
      Lack of opacification of the gall bladder (due to               Position of caecum and ileo-caecal angle
          lack of capacity to absorb and concentrate by gall      Commonly seen lesions are –
          bladder)                                                      Carcinoma
      Lack of contractility of gall bladder (due to                   TB
          thickened, fibrosed and non-contractile wall)                 Polyps, diverticula, stricture
      Filling defects due to calculi
   This test is useful in identifying diverticulae, polyps     Double contrast barium study
     and to assess the function of gall bladder.                 To study the mucosal pattern of the bowel, air and thin
                                                                 barium are injected into the colon and X ray examination is
Contra indications                                               done in supine, lateral and erect postures.
   Jaundice (the dye is not excreted by liver – hence the
     test is inconclusive)
                                                                 The findings of certain diseases
                                                                 Ulcerative tuberculosis


                                                                                               Yogiram’s Lectures on Surgery
74 Diagnostic radiology

 Spasm of involved segment is present (non filling of              It should be avoided in the following cases
   ascending colon and ileum.)                                       H/o allergic disorders
Hype plastic tuberculosis (chronic                                   Familial history of idiosyncrasy to iodine drugs
granulomatous lesion)                                                Pregnant people (In married and fertile women, I.V.P
 Filling defect – due to mass                                        is not advised 15 days after menstrual period for the
                                                                       fear that she might be pregnant )
 Short ascending colon (Caecum pulled up from right
   iliac fossa due to chronic pericolic                              Dehydration
   fibrosis).(Normally, caecum lies below iliac crest)               Multiple myeloma
 Irregular, shortened, narrowed and deformed caecum             Observation:
 Distorted ileocaecal junction with incompetent and                At 3 minutes, renal shadows are seen prominently
   obtuse ileocaecal angle                                             (nephrogram phase)
 Dilated ileum                                                     At 5-10 min:- major,minor calyces, and pelvis is seen
Carcinoma                                                              on IVP
   Irregular intraluminal and persitent filling defect             At 10-15 min- bladder as round supra pubic structure
     (apple-core deformity)                                            is seen
                                                                     After 30 min:-post void film shows no residual urine
Intra Venous Pyelography (IVP)                                          In vesico ureteral reflux, post voiding film shows
                                                                            lower end of ureters filled with the dye
Principle:
                                                                  Observe for –
   Water soluble radio contrast dye (Sodium
     diatrizoate(Conray) (safe dose: 300 mg) or Trivideo is         Kidneys and ureters on both sides
     injected which is excreted by kidneys into urinary             Size of the calyces and the pelvis or ureter
     tract and X-rays are taken during the excretion of the         Shape of the calyceal ends
     dye by the kidneys                                             Filling defects in the calyces, pelvis or ureter
   It is an anatomical and functional investigation of            Deformity or displacement of the calyces
     urinary tract                                                     Spider leg deformity = ca, cyst, polycystic disease
   It takes 5-10 min for the dye to enter the calyces, 15-       Filling defects in the bladder
     20 min to enter bladder                                           Carcinoma, BPH, radiolucent stone
Preparation:                                                       Common lesions are -
                                                                       Hydronephrosis, carcinoma, papilloma
   Laxatives (mineral free) like senna, charcoal tabs. and
     methyl polysilaxone are administered for two days            IVP changes in hydronephrosis
     prior to the examination                                        a) Changes in pelvis  pelvis is dilated
   12 hours fasting                                                b) Changes in calyces
Observation:                                                            Early changes -- calyces flattened and later, club
                                                                           shaped
It is shown as contrast of
                                                                        In advanced cases, where the renal parenchyma is
 3 major calyces  upper, middle and lower                               thin and poorly functioning, hydronephrosis is
 7minor calyces  3 for upper calyx; 2 for middle                        demonstrated by a large renogram (enhanced
      calyx and 2 for lower calyx                                          renal shadow) with dilated calyces faintly seen in
 The ureter is shown as peristaltic contractions. Whole                  the renogram as soap bubbles
      of ureter is seen only in obstruction of ureter                   In suspected cases where there is no excretion of
Method                                                                     the dye, a twenty-four film after the injection of
                                                                           the dye is useful as it may demonstrate dilated
   The dye is injected I.V. not exceeding 300 mg and
                                                                           urinary tract upto the level of obstruction, as a
     repeated films are taken at regular intervals depending
                                                                           mild denser shadow
     on the lesion suspected
   Test dose of 2-3 ml is given intravenously before            CHEST RADIOGRAPHY
     administering the drug and all emergency drugs for
     managing anaphylactic reaction are kept ready                Radiological findings to be observed
   In renal failure, IVP is of no use, as the failing kidneys
     do not excrete contrast. Hence, large doses may be              Rib cage, thoracic inlet and spine
     given to enhance the contrast excretion as infusion             Diaphragmatic outline
     (infusion pyelogram)                                            Mediastinum
Precautions:                                                         Lung shadows
                                                                        Infiltrations

Yogi Ram’s lectures on Surgery
                                                                                 Diagnostic radiology 75

           Local, diffuse, patchy                   Cholesteotoma
        Miliary lesions
        Coin lesions (dense shadows of < 4cms)   Osteosclerotic lesions
        Mass lesions (dense shadows of > 4cms)      Osteoma
        Atelectasis                                 Paget’s disease
        Honey-combing                               Secondaries from ca prostate
        Cavity
                                                   DD of benign and malignant masses from
Coin lesions                                       bone
   Granuloma, especially tuberculosis               Benign
   Malignant tumour                                    Clear transition zone between tumour and
   Cyst –hydatid                                          surrounding normal bone
   Hamartoma                                           Sclerosis at the margins
   Lymphoma                                         Malignant
   Chest wall lesions                                  Destruction of normal bone
      Mesothelioma, fibroma of pleura                  No transition between mass and the surrounding
Multiple coin lesions                                       bone
   Secondaries                                         Matrix and periosteal new bone formation
   Hydatid cysts                                 Ultrasound scan
   Staphylococcal bronchopneumonia               General principles of Ultra sound scan
Mass lesions                                          Sound waves at frequency of 3 – 20 MHz are
   Solitary                                           generated by piezo-electric crystals and passed
      Hydatid                                         through the body tissues
      Dermoid                                       The reflected waves (echoes) are picked by the same
      Lung abscess                                    transducer and sends it to a monitor where they are
      Carcinoma                                       converted to electric impulses and displayed on the
   Multiple                                           monitor
   Secondaries                                      The greater the frequency of the sound wave, lesser is
   Hydatid cysts                                      its penetration and greater is the resolution of the
                                                        tissue
Mediastinal masses                                       3 MHz is used for scanning of abdominal organs
                                                         7.5 MHz is used for scanning of thyroid, breast,
Mass lesions on lateral view                                 trans vaginally the pelvic organs
   Anterior (to tracheal shadow)                       10 MHz is used for endorectal evaluation
      3ts – teratoma, thymoma, thyroid                 12 –20 MHz is used for endoscopic
   Middle (between trachea and spine)                      ultrasonography to scan the gut wall
      Bronchial cyst, aortic aneurysm               The tissues depending upon their density and speed of
   Posterior (to anterior border of spine)            acoustic wave transmits or reflects the sound wave
      Neural tumours                                   The reflected wave intensity (echo) is dependent
                                                             upon the difference in the acoustic impedance of
SKULL LESIONS                                                the tissues at their interface
                                                      The solids (bone, calculus) have high intensity echoes
There are two types of lesions –                        and liquids have no echoes
 Osteolytic lesions                                 High intensity echoes are called as hyper echoic
 Osteosclerotic lesions                               (appear as whiter)
Osteolytic lesions                                       When all the waves are reflected, nao sound wave
                                                             passes through the tissue and the tissue casts a
   Dermoid                                                 shadow (acoustic shadow)
   Secondary                                        No intensity echoes are called as anechoic (appear as
   Aneurysmal bone cyst                               black or dark)
   Histiocytoma                                     The other echo densities are – hypo echoic and iso
   Eosinophilic granuloma                             echoic
   Hydatid cyst                                  Modes of ultra sound scanning
   Syphilis

                                                                               Yogiram’s Lectures on Surgery
76 Diagnostic radiology




A mode: amplitude modulation
 One dimensional image that displays amplitude of the
   wave
B mode: brightness modulation
 Amplitude of the wave is displayed as brightness
   (denser structures are displayed as whiter, i.e.,
   hyperechoic)
 This is the mode used in clinical practice
M mode: motion modulation
 Wave pattern is related to motion, e.g., cardiac muscle
 Nowadays real time sonography has replaced M mode
   cardiac echography
Doppler coupled B mode scanning (colour
Doppler or Duplex scan)
   Used to study flow in the blood vessels
Ultra sound scanning - Clinical uses of ultra
sound
   Abdominal ultrasonography
      It is used to evaluate the solid and fluid filled
          viscera in the abdominal cavity, e.g., liver,
          pancreas, kidney, uterus, gall bladder, urinary
          bladder etc.
   Trans rectal to scan the prostate and trans vaginal for
     pelvic viscera, especially ovulation studies
   Thyroid and breast
      For evaluation of solid and liquid masses
   Endoscopic ultra sonography (EUS)
      The wall of the gut can be evaluated to stage the
          T stage of the disease
      To evaluate fistulous track in fistula in ano
      To study the sphincters in anal incontinence
      To study common bile duct and head of pancreas
          in cholestatic jaundice
   Intraoperative (laparoscopic) ultrasonography
      To evaluate hepatic, biliary and pancreatic lesions
          to plan the operative strategy
   Vascular system
      Duplex colour scanning is used to evaluate the
          flow pattern of the vessels – DVT, occlusive
          arterial disease, portal vein flow, vascularity of
          the organs and tumours
   Guided FNAC / trucut biopsy



Yogi Ram’s lectures on Surgery